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ATLAS  AND  EPITOME 


OF 


ABDOMINAL  HERNIAS 


BY 

DR.  GEORG  SULTAN 

First  Assistant  in  the  Surgical  Clinic  in  Gbttingen,  Prussia 


AUTHORIZED  TRANSLATION  FROM  THE  GERMAN 


EDITED  BY 

WILLIAM  B.  COLEY,  M.D. 

Clinical  Lecturer  on  Surgery,  Columbia  University  (College  of  Physicians  and 

Surgeons)  ;  Surgeon  to  the  General  Memorial  Hospital;  Assistant 

Surgeon  to  the  Hospital  for  Ruptured  and  Crippled, 

New  York  City 


With  l\9  Illustrations,  36  of  them  in  Colors 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  &  COMPANY 
^902 


Copyright,  1902,  by  W.  B.  SAUNDERS   &    COMPANY. 


Registered  at  Stationers'  Hall,  London,  England. 


ELECTROTYPED  BY  PRESS  OF 

WESTCOTT  &  THOMSON,   PHILADA.  W.   B.   SAUNDERS  &  COMPANY- 


EDITORIAL  NOTE. 


This  '•'■  Atlas  of  Abdominal  Hernias ''  is  certainly  a 
most  timely  publication,  and  fills  a  long-felt  want  on  the 
part  of  the  general  practitioner.  The  illustrations  are  not 
only  very  numerous,  but  they  excel  in  character  those  of 
any  other  work  upon  hernia  with  which  the  writer  is 
familiar.  While  the  w^ell-kuown  work  of  Macready  will 
always  remain  a  classic,  and  will  continue  to  be  consulted 
as  much  as  ever  by  all  who  desire  to  make  a  comprehensive 
study  of  hernia,  this  w^ork  has  never  made  any  claims  to 
deal  with  the  operative  side  of  the  subject,  and  this  is  a 
side  that  has  been  steadily  growing  in  importance  the  last 
decade,  until  now  it  is  absolutely  essential  to  have  a  book 
to  supplement  such  a  treatise  as  Macready\s.  The  present 
atlas  of  Sultan's  seems  to  do  this  to  an  admirable  de- 
gree, and  I  believe  it  will  prove  of  very  great  value  to 
the  general  surgeon  as  well  as  to  the  general  practitioner. 

William  B.  Coley. 

New  York,  June^  1902. 


PREFACE. 


The  subject  of  abdominal  hernia  is  one  of  the  most 
important  in  the  entire  domain  of  medical  teaching,  since 
these  hernias  are  not  only  exceedingly  common,  but  the  fre- 
quent occurrence  of  strangulation  demands  extraordinarily 
quick  and  energetic  surgical  intervention.  In  this  respect 
the  responsibility  of  the  physician  is  unusually  great,  and 
he  will  have  to  decide  between  the  life  and  death  of  the 
patient  intrusted  to  his  care  more  often,  probably,  than 
in  any  other  affection.  The  treatment  is  productive  of 
better  results  than  in  other  affections,  provided  the  condition 
is  recognized  early  and  that  this  recognition  is  followed 
by  the  proper  therapeutic  measures.  In  order  to  meet 
these  responsibilities,  however,  a  most  thorough  knowledge 
of  the  entire  subject  is  necessary,  and  the  details  of  this 
subject  extend  over  a  wide  field. 

If  this  book  should  succeed  in  awakening  an  interest 
in  abdominal  hernias  among  physicians  and  students,  and 
in  inciting  them  to  a  careful  study  of  the  subject,  I  shall 
consider  that  my  labors  have  been  rewarded. 

Professors  Braun,  Orth,  and  Merkel,  of  Gottingen, 
have  greatly  assisted  me  by  placing  at  my  disposal  the 
abundant  material  of  the  Surgical  Clinic  and  that  of  the 
Institutes  of  Anatomy  and  Pathology.  I  am  also  indebted 
to    Professor  Nauwerck,  of  Chemnitz,  for  two  valuable 

11 


12  PREFACE. 

specimens,  and  to  Professor  Reichel,  of  Chemnitz,  who 
allowed  me  to  use  one  of  his  clinical  records.  This 
volume  has  been  rendered  possible  only  by  kind  assistance 
from  many  quarters,  and  I  take  this  opportunity  to 
express  my  most  sincere  thanks  to  all  the  gentlemen  who 
have  aided  me. 

All  the  illustrations,  except  those  prepared  from  photo- 
graphs taken  by  myself,  were  drawn  by  Mr.  Braune,  of 
Kdnigsberg,  to  whom  I  desire  to  express  my  sj^ecial 
indebtedness  for  his  clear  understanding  and  untiring 
energy. 

Thanks  must  also  be  given  to  Professor  Wilhelm 
Schultze,  of  G5ttingen,  for  etymologic  information,  and, 
last,  but  not  least,  to  Mr.  Lehmann,  who  has  greatly 
added  to  the  value  of  the  work  by  his  careful  attention  to 
the  details  of  its  publication. 

Froriep's  plates  have  been  utilized  in  drawing  Figs. 
2,  4,  5,  and  6,  and  Figs.  39  and  95  were  taken  from  the 
plates  of  Nuhn. 

Further  details  in  reference  to  the  cases  illustrated  in 
Plate  7,  and  in  Figs.  90,  104,  and  106,  will  be  found  in 
a  work  by  Dr.  Fertig,  of  Gottiugen,  which  will  shortly 
make  its  appearance. 

Georg  Sultan. 


CONTENTS. 


HERNIA  IN  GENERAL. 

PAGE 

Definition 17 

Frequency  of  Hernia 18 

Mouth  of  the  Hernia 19 

Sac  of  the  Hernia 31 

Contents  of  the  Hernia 35 

Coverings  of  a  Hernia 45 

Subperitoneal  Lipomas 47 

Origin  of  Abdominal  Hernias 50 

General  Diagnosis  of  Hernia 58 

General  Treatment 63 

PaUiative   64 

Radical  Operation 68 

The  Accidents  of  Hernia 80 

Fecal  Stasis 80 

Inflammation  of  a  Hernia 82 

Strangulation  of  a  Hernia 87 

Elastic  Strangulation 88 

Fecal  Strangulation 91 

Symptoms  and  Course  of  Intestinal  Stran- 
gulation      99 

Strangulation  of  Omentum 103 

Retrograde    Strangulation 106 

Treatment  of  Strangulated  Hernia 107 

Taxis 107 

Apparent  Reduction 114 

Herniotomy 115 

Resection  of  Intestine 126 

Artificial  Anus 126 

Expert    Opinions  in   Reference  to  Abdominal 

Hernias 135 

13 


14  CONTENTS. 

SPEQAL  HERNIAS. 

PAGE 

Inguinal  Hernia 139 

Anatomy  of  the  Inguinal  Region 139 

External  Inguinal  Hernia 143 

Congenital  Inguinal  Hernia 143 

Acquired  External  Inguinal  Hernia 146 

Internal  Inguinal  Hernia 148 

Diagnosis  of  Internal  Inguinal  Hernia 150 

Interparietal  Inguinal  Hernia 166 

Properitoneal  Inguinal  Hernia 167 

Interstitial  Inguinal  Hernia 167 

Superficial  Inguinal  Hernia ; 168 

Treatment  of  Inguinal  Hernia 169 

Truss  in  Treatment  of  Inguinal  Hernia 169 

Radical  Operation  in  Treatment  of  Inguinal 

Hernia 172 

Bassini's  Method 173 

Kocher's  Method 175 

Macewen's  Method 180 

Femoral  Hernia 185 

Anatomy  of  the  Femoral  Region 186 

Diagnosis  of  Femoral  Hernia 190 

Strangulation  of  Femoral  Hernias 199 

Treatment  of  Femoral  Hernia 201 

Truss  in  Treatment  of  Femoral  Hernia 201 

Radical  Operation  in  Treatment  of  Femoral 

Hernia 202 

Bassini's  Method 204 

Kocher's  Method 205 

Salzer's   Method 206 

Schwartz's  Method 206 

Trendelenburg- Kraske  Method 206 

Witzel's  Method 207 

Umbilical  Hernia 208 

Congenital  Umbilical  Hernia 209 

Treatment 213 

Umbilical  Hernia  of  Children 215 

Treatment    217 

Umbilical  Hernia  in  Adults 222 

Treatment    227 


CONTENTS.  15 

PAGE 

Obturator  Hernia 230 

Anatomy  of  the  Obturator  Region 230 

Diagnosis  of  Obturator  Hernia 232 

Treatment  of  Obturator  Hernia 234 

Sciatic  Hernia 235 

Perineal  Hernia 238 

Inguino-perineal  Hernia 243 

Diaphragmatic  Hernia 244 

Ventral  Hernia 250 

Hernia  of  the  Linea  Alba 250 

Lateral  Ventral  Hernia 260 

Lumbar  Hernia 262 

Internal  Hernias 265 

Hernia  of  Foramen  of  Winslow 266 

Hernia  of  Duocleno-jejunal  Recess 266 

Hernia  of  Retrocecal  and  Ileocecal  Recesses.  .  .  .   267 

Hernia  of  Intersigmoid  Recess 269 

Retrovesical  Hernia 269 

Treatment  of  Internal  Hernias 271 


Index 273 


HERNIA  IN  GENERAL. 


An  abdominal  hernia  is  a  peritoneal  protrusion  Avhich 
temporarily  or  permanently  contains  any  abdominal  vis- 
cus.  The  hernia  is  more  definitely  designated  by  the 
name  of  the  anatomic  region  through  which  the  peritoneal 
protrusion  takes  place  (inguinal  hernia,  diaphragmatic 
hernia,  umbilical  hernia).  The  word  "  rupture,"  as 
applied  to  this  condition,  is  to  be  explained  by  the  old 
supposition  that  in  those  hernias  which  suddenly  make 
their  appearance,  the  protrusion  of  the  abdominal  viscus 
must  be  preceded  by  a  laceration — ruptura — of  the  parietal 
peritoneum.  At  the  present  time  it  is  known  that  this  idea 
is  erroneous.  Another  name  in  still  more  common  use  has 
been  formed  with  the  aid  of  the  Greek  Avord  hele  (enteroGele, 
intestinal  hernia ;  epiplocele,  omental  hernia),  and  these 
combinations  at  once  reveal  the  nature  of  the  hernial  con- 
tents. It  must,  however,  be  remembered  that  this  termi- 
nation is  used  not  only  to  designate  hernias,  but  that  it  is 
also  employed  in  reference  to  swellings  resembling  them 
(hydrocele,  varicocele). 

The  etymologic  derivation  of  the  word  hernia  from  the 
Greek  rd  ipvo^,  ^^ sprout,"  '^outgrowth,"  as  given  in  some 
text-books,  is  just  as  incorrect  as  is  the  attempted  deduc- 
tion from  hira,  ''jejunum."  "Hernia"  is  an  old  Latin 
word  which  seems  to  have  always  had  its  present  signific- 
ance and  the  exact  etymology  of  which  is  unknown.  Some 
have  assumed  that  there  is  a  relation  between  the  endings 
2  17 


18  HERNIA, 

Xyj^  and  x'>iXd^,  ''hollow/'  but  this  is  also  wrong,  since 
X^j^^  has  also  had  the  significance  of  ''rupture"  since  time 
immemorial,  as  is  shown  by  the  etymologic  agreement  of 
the  CJreek  word  with  the  designation  of  the  affection  in  old 
Bulgarian  {kyla)  and  in  old  Scandinavian  (haull).  (From 
a  personal  communication  from  Professor  Wilhelm  Schultze, 
of  Gottingen.) 

An  idea  of  the  frequency  of  hernia  may  be  obtained 
from  a  study  of  the  statistics  of  Berger,  which  are  based 
upon  the  observation  of  10,000  cases  of  hernia,  and  which 
are  of  particular  value,  since  the  number  of  cases  occur- 
ring among  Parisians  of  a  certain  age  are  compared  with 
the  total  number  of  the  Parisian  population  at  the  same 
age.  Considerable  and  interesting  differences  are  found  to 
exist  in  different  periods  of  life. 

In  every  1000  individuals  in  the  1st  year  of  life  there  are  19.6  cases  of  hernia. 

From  the  1st  to  the  4th  year  of  life  there  are 4.2  "  "  " 

In  "    5th''  "    9th  years"  "  "  "  1.89  "  "  " 

"  "10th"  "14th  "  "  "  "  "  1.35  "  "  " 

"  "15th"  "19th  "  "  "  "  "  1.14  "  "  " 

"  "20th"  "24th  "  "  "  "  "  0.88  "  "  " 

"  "25th"  "29th  "  "  "  "  "  1.25  "  "  " 

«  "  30th  "  "  ,34th  "  "  "  "  "  2.02  "  "  " 

"  "35th"  "39th  "  "  "  "  "  3,32  "  "  " 

"  "40th"  "44th  "  "  "  "  "  4.67  "  "  " 

"  "45th"  "49th  "  "  "  "  "  5.73  "  "  " 

"  "50th"  "54th  "  "  "  "  "  7.97  "  "  " 

"  "55th"  "59th  "  "  "  "  "  9.52  "  "  " 

"  "60th"  "64th  "  "  "  "  "  14.03  "  "  " 

"  "65th"  "69th  "  "  "  "  "  20.73  "  "  " 

«  "70th"  "74th  "  "  "  "  "  24.20  "  "  " 

"  "75th"  "79th  "  "  "  "  "  21.60  "  "  " 

"  "80th"  "84th  "  "  "  "  "  15.03  "  "  " 

"  "85th"  "89th  "  "  "  "  " 5.09  "  "  " 

«  "90th"  "94th  "  "  "  "  "  1.25  "  "  " 

The  relatively  large  number  of  hernias  in  the  first  year 
of  life  rapidly  decrease  with  the  beginning  of  the  second 


MOUTH  OF  THE  HERNIA.  19 

year,  and  then  slowly  and  uniforndy  diminish  until  i\w 
minimum  is  ivacliod  in  the  twentieth  to  the  twenty-fourth 
year.  The  number  gradually  increases  until  the  sixtieth 
year  is  reached,  when  it  suddenly  rises,  and  the  maximum 
is  attained  in  the  seventieth  to  the  seventy-fourth  year. 
From  the  eightieth  to  the  ninetieth  year  the  number  of 
cases  again  drops  suddenly.  Men  are  more  frequently 
aifected  with  hernia  than  women  in  the  proportion  of  three 
to  one.  The  table  just  quoted  shows  that  the  number  of 
cases  of  hernia  in  1000  of  the  average  population  is  about 
4.4.  This  proportion  is  by  no  means  absolute,  since  there 
are  great  variations  in  different  countries,  and  even  in 
different  parts  of  the  same  country. 

Every  completely  formed  hernia  possesses  a  mouth,  a 
sac,  certain  coverings,  and  contents. 

The  mouth  of  the  hernia  is  the  opening  in  the  abdo- 
minal wall  through  which  the  hernia  leaves  the  abdomen. 
If  this  opening  passes  directly  through  the  abdominal 
wall,  as  in  an  umbilical  hernia,  so  that  the  canal  is  very 
short,  it  is  designated  the  hernial  ring.  If  the  canal  is 
longer,  and  particularly  if  it  passes  obliquely  through  the 
abdominal  ^vall,  as  in  the  inguinal  region,  we  may  speak  of 
an  internal  and  of  an  external  ring.  The  seats  of  predi- 
lection for  the  formation  of  a  hernial  mouth  or  orifice  are 
to  be  found  in  those  places  in  which  the  abdominal  wall  is 
more  yielding,  where  its  structure  is  weaker,  and  these 
situations  are  chiefly  those  in  which  the  larger  vessels  and 
nerves  normally  pass  through  the  abdominal  wall.  The 
spermatic  cord,  which  traverses  the  abdominal  parietes 
obliquely,  serves  as  a  guide  for  the  external  inguinal 
hernia,  the  mouth  of  which  is  consequently  identical  with 


20  HERNIA. 

the  inguinal  canal ;  the  femoral  hernia  passes  out  with  the 
femoml  vessels,  finally  making  its  appearance  at  the  saph- 
enous opening,  and  in  the  same  manner  the  umbilical, 
obturator,  and  sciatic  vessels  determine  the  direction  of  a 
hernia  occurring  in  these  situations.  A  hernial  orifice  may 
also  be  formed  in  those  situations  where  there  is  a  gap  in 
the  musculature,  as  in  some  cases  of  diaphragmatic  and 
lumbar  hernia.  The  development  of  a  hernia,  however,  is 
favored  not  only  by  pre-existing  apertures,  but  it  some- 
times suffices  that  the  abdominal  wall  is  thinner  in  certain 
situations,  whether  it  be  because  the  normal  structure  is 
weaker,  or  whether  it  has  become  thinned  by  pathologic 
conditions,  suppurations,  or  preceding  operations.  Such 
weak  places  are  to  be  found  in  the  internal  inguinal  fossa 
(internal  inguinal  hernia),  in  the  linea  alba  (hernia  of  the 
linea  alba,  epigastric  hernia),  as  well  as  in  other  portions 
of  the  anterior  abdominal  wall,  particularly  at  the  outer 
edge  of  the  rectus  (ventral  hernia),  and  in  certain  places 
in  the  pelvic  floor  (perineal  hernia).  For  the  sake  of  com- 
pleteness, mention  should  also  be  made  of  congenital  mal- 
formations or  fissures  through  which  a  completely  developed 
hernia  with  all  its  parts  may  protrude  at  birth.  Snch  fissures 
are  observed  chiefly  at  the  umbilicus  and  in  the  diaphragm. 
There  is  one  group  of  hernias,  the  so-called  internal 
hernias,  which  have  no  actual  hernial  orifice.  In  these 
cases  the  peritoneal  diverticulum  is  situated  between  the 
abdominal  wall  and  the  parietal  peritoneum,  and  is  nothing 
more  nor  less  than  an  expansion  of  a  pre-existing  peri- 
toneal recess.  In  those  internal  hernias  which  protrude 
into  the  lesser  peritoneal  cavity,  however,  the  foramen  of 
Winslow  may  be  regarded  as  the  hernial  orifice. 


MOUTH  OF  THE  HERNIA.  21 

A  brief  anatomic  survey  %vill  he  of  service  in  explaining 
the  situation  of  the  most  important  hernial  orifices,  and,  at 
the  same  time,  Avill  show  how  the  seats  of  predilection  for 
the  development  of  hernias  are  dependent  upon  the  anat- 
omic peculiarities  of  the  abdominal  walls. 

An  inspection  of  the  anterior  abdominal  wall  of  a  mus- 
cular and  not  too  fat  individual  (Fig.  1)  reveals  a  series  of 
depressions  and  elevations  the  location  of  which  must  be 
known  in  order  to  avoid  being  led  into  error  by  their  mis- 
interpretation. Upon  each  side  of  the  middle  line  there  is 
a  longitudinal  elevation  which  gradually  becomes  flatter  as 
it  approaches  the  pelvis,  and  which  corresponds  to  the 
position  of  the  rectus  muscle.  The  external  border  of  the 
muscle  is  particularly  well  marked,  and  three,  sometimes 
four,  broad  transverse  furrows  indicate  the  position  of  the 
tendinous  intersections.  These  two  longitudinal  elevations 
are  separated  in  the  median  line  by  a  narrow  groove  which 
passes  through  the  umbilicus  and  gradually  disappears 
midway  between  this  point  and  the  symphysis.  At  the 
outer  side  of  the  rectus  muscle  another  furrow  is  observed, 
which  runs  at  first  from  above  directly  do^^^lward,  then 
toward  the  median  line,  and  which  marks  the  situation  in 
which  the  muscular  portion  of  the  external  oblique  joins 
with  its  aponeurosis.  The  external  oblique  muscle  itself 
forms  a  flat  elevation  the  serrated  origin  of  Avhich  is  dis- 
tinctly marked,  interdigitating  with  the  serratus  magnus 
and  with  the  latissimus  dorsi.  The  prominence  below  the 
flat  elevation  of  the  external  oblique  is  the  anterior  superior 
spine  of  the  ilium,  and  the  anatomic  base  of  the  groove 
running  from  this  prominence  to  the  symphysis  is  formed 
by  Poupart's   ligament.     For  the   sake  of  uniformity  of 


22 


HERNIA. 


MOUTH  OF  THE  HERNIA.  23 

Fig.  1. — The  outline  at  the  right  of  the  illustration  gives  the  names 
of  the  different  abdominal  regions  and  also  designates  the  positions  at 
which  the  various  hernias  make  their  appearance. 

The  illustration  itself  reveals  the  elevations  and  depressions  of  the 
anterior  abdominal  wall  of  a  very  muscular  subject  containing  little 
fat.  The  middle  line  of  the  alxlomen — the  linea  all)a — is  indicated  by 
a  furrow  which  gradually  becomes  indistinct  and  disappears  midway 
between  the  umbilicus  and  the  symphysis.  The  longitudinal  eleva- 
tions on  either  side  are  caused  by  the  recti  muscles,  the  tendinous  inter- 
sections of  which  are  distinctly  marked.  The  flat  elevation  Just  above 
the  anterior  superior  spine  of  the  ilium  is  formed  by  the  external 
oblique  muscle,  and  the  groove  running  from  this  spine  to  the  sym- 
physis lies  over  Poupart's  ligament. 

description  of  the  different  abdominal  regions  the  following 
lines  are  drawn  :  (1)  A  line  connecting  the  lowest  point 
of  the  costal  margin  of  one  side  with  the  corresponding 
point  upon  the  opposite  side.  (2)  A  line  connecting  the 
highest  point  of  the  crest  of  the  ilium  of  one  side  (viewed 
anteriorly)  with  the  corresponding  point  upon  the  opposite 
side.  (3)  Tw^o  oblique  lines  from  the  end  of  the  tenth 
ribs  to  the  pubic  spines  of  the  same  side. 

Above  the  first  line,  in  the  middle,  is  the  epigastric 
region,  with  the  right  and  left  hypochondriac  regions  on 
either  side.  Between  the  first  and  second  lines  is  the 
mesogastric  region,  made  up  of  the  umbilical  region  in  the 
center,  with  the  right  and  left  lateral  abdominal,  iliac,  or 
lumbar  regions  at  either  side.  Below  the  second  line  is  the 
hypogastric  region,  composed  of  the  pubic  region  or  hypo- 
gastrium  in  the  center  with  the  right  and  left  inguinal 
regions  at  the  sides.  The  crural  or  femoral  region  com- 
mences at  Poupart's  ligament  and  extends  downward. 

The  superficial  fascia  is  exposed  by  the  removal  of  the 
skin  (see  Fig.  2),  and  upon  its  surface  are  observed  small 


24  HERNIA. 

Fig.  2. — The  anterior  abdominal  wall  after  removal  of  the  skin : 
The  superficial  fascia  is  exposed  and  through  its  substance  the  under- 
lying external  oljlique  muscle  may  be  seen.  The  continuation  of  the 
fascia  upon  the  thigh  is  perforated  by  the  great  saphenous  vein;  in  this 
situation  it  exhibits  a  number  of  sieve-like  perforations  and  is  known 
as  the  cribriform  fascia. 

Fig.  3. — The  anterior  abdominal  wall  after  removal  of  the  super- 
ficial fascia:  The  most  external  of  the  abdominal  muscles — the  exter- 
nal oblique — is  exposed ;  the  muscular  fibers  soon  spread  out  into  a 
broad  aponeurosis  the  lower  free  margin  of  which  is  Poupart's  liga- 
ment. The  aponeurosis  ends  at  the  pubic  spine  with  a  sharp  border, 
the  convexity  of  which  is  directed  outward  and  which  bounds  an 
opening — the  external  abdominal  ring — through  which  the  spermatic 
cord  passes  out  of  the  abdomen. 

In  the  femoral  region  the  fascia  lata  is  exposed.  The  curved  free 
edge  of  this  fascia — the  falciform  process — is  situated  below  the  inner 
third  of  Poupart's  ligament  and  embraces  the  saphenous  opening, 
through  which  the  femoral  vein  and  a  narrow  edge  of  the  femoral 
artery  are  visible.  The  f  designates  the  position  in  which  femoral 
hernia  makes  its  appearance. 

vascular  ramifications  which  have  no  practical  importance. 
The  superficial  fascia  is  continued  upon  the  thigh,  in  one 
place  exhibiting  sieve-like  perforations ;  this  portion  is 
known  as  the  cribriform  fascia,  and  one  of  its  openings 
gives  passage  to  the  great  saphenous  vein.  The  super- 
ficial fascia  of  the  abdomen  is  also  continuous  with  the 
superficial  fascia  of  the  scrotum,  in  which  situation  it  is 
known  as  the  dartos. 

Figure  3  represents  the  structures  which  are  exposed 
upon  the  removal  of  the  superficial  fascia.  The  fibers  of 
the  external  oblique  muscle  run  from  above  downward 
and  inward.  They  arise  by  a  number  of  digitations  from 
the  seven  lower  ribs  and  s])read  out  into  a  broad  aponeuro- 
sis which  ends  in  the  median  line  in  the  linea  alba  and 


Fiy.:^ 


Vena 
saphena  magna. 


FUj.  S. 


M.  obliquus  externus 


Annulus 
iiig-uinalis  subcutaneus, 
Funiciilus  spermaticus, 

i 

Vena  femoralis 
Art.  femoralis 


Vena  saphena  mag-na 


MOUTH  OF  THE  HERNIA.  25 

below  in  Pouparfs  ligament.  At  the  inner  end  of  this 
ligament  there  is  a  concave  free  border,  the  concavity  of 
which  is  directed  downward  and  inward  and  beneath  which 
the  spermatic  cord  passes  ont  of  the  abdomen.  This  open- 
ing, which  represents  the  outer  end  of  the  inguinal  canal, 
is  called  the  external  abdominal  ring.  The  prolongations 
of  the  aponeurosis  which  form  the  upper  and  lower  boun- 
daries of  the  ring  are  known  respectively  as  the  superior 
and  the  inferior  pillars.  It  is  in  this  situation  that  inguinal 
hernia  makes  its  appearance.  If  the  scrotum  of  such  a 
patient  is  invaginated  and  the  index-finger  introduced  into 
the  canal,  the  sharp  margin  of  the  ring  is  almost  always 
distinctly  felt  and  an  exact  idea  of  the  size  of  the  hernial 
orifice  may  be  obtained. 

The  femoral  region  is  covered  by  the  fascia  lata,  with 
the  exception  of  the  saphenous  opening,  which  is  situated 
immediately  beneath  the  cribriform  fascia.  This  opening 
is  semilunar  in  shape  with  the  convexity  directed  upward 
and  outward.  That  portion  of  the  fascia  lata  forming  the 
upper  and  outer  border  of  the  saphenous  opening  is  known 
as  the  falciform  process.  Through  this  opening  a  portion 
of  the  femoral  vein  is  observed  into  which  the  great 
saphenous  vein  empties,  and  to  the  outer  side  of  the  vein 
a  narrow  margin  of  the  femoral  artery  may  be  seen. 
Femoral  hernia  makes  its  appearance  at  the  upper  portion 
of  the  saphenous  opening  and  internal  to  the  femoral  vein, 
as  indicated  by  the  t  ii^  the  figure. 

In  figure  4  the  external  oblique  muscle  and  a  portion  of 
the  fascia  lata  have  been  removed  so  that  the  internal 
oblique  muscle  is  exposed  to  view.  Tliis  muscle  arises 
from  the  lumbar  fascia,  from  the  crest  of  the  ilium  as  far 


26  HERNIA. 

Fig.  4. — The  anterior  abdominal  wall  after  removal  of  the  external 
oblique  muscle:  The  internal  oblique  miiscle  is  seen  passing  toward 
the  middle  line;  it  is  inserted  into  a  broad  aponeurosis,  and  some  iso- 
lated libers  of  the  lower  portion  of  the  muscle  are  continued  upon  the 
spermatic  cord  and  testicle  under  the  name  of  the  cremaster  muscle. 
The  fascia  lata  has  been  partly  removed  from  the  femoral  region  so 
that  the  femoral  vessels  are  exposed.  The  vein  lies  to  the  inner,  the 
artery  to  the  outer  side.  The  lymphatic  gland  situated  at  the  inner 
side  of  the  vein  is  known  as  the  gland  of  Rosenmiiller. 

Fig.  5. — The  anterior  abdominal  wall  after  removal  of  the  internal 
oblique  muscle  of  the  aponeurotic  layers  covering  the  rectus  muscle: 
The  rectus  muscle  with  its  tendinous  intersections  is  exposed,  and  to 
the  outer  side  of  the  rectus  the  transversalis  is  observed.  The  latter 
muscle  has  a  sharp  Inferior  border  which  passes  over  the  posterior  por- 
tion of  the  spermatic  cord.  The  spermatic  cord  itself  is  exposed  up  to 
the  point  where  it  makes  its  exit  through  the  internal  abdominal  ring. 

In  the  femoral  region  the  muscles  are  exposed  with  the  exception  of 
the  pectineus,  which  is  still  covered  by  the  deep  fascia. 

forward  as  the  anterior  superior  spine,  and  from  Poupart's 
ligament.  The  most  posterior  fibers  pass  vertically  upward 
and  are  inserted  into  the  three  lower  ribs ;  the  adjoining 
fibers  pass  upward  and  inward  and  the  more  anterior  ones 
directly  inward,  while  those  most  anterior  run  parallel  to 
the  course  of  Poupart's  ligament.  By  far  the  greater  por- 
tion of  the  fibers  are  inserted  into  a  broad  aponeurosis 
which  divides  into  two  layers.  The  spermatic  cord  is  seen 
passing  upward  and  outward  within  the  abdominal  wall ; 
some  muscular  fibers  from  the  lower  edge  of  the  internal 
oblique  are  prolonged  upon  the  spermatic  cord  and  testicle 
(cremaster  muscle).  In  the  femoral  region  tlie  vessels  are 
more  freely  exposed,  and  to  their  outer  side  the  edge  of  the 
sartorius  is  observed.  A  lymphatic  gland  is  frequently 
found  at  the  inner  side  of  the  vein  in  the  position  at  which 
femoral  hernia  makes  its  appearance. 


Fig.  4. 


M.  oblicjuus  interniis. 


Funiculus  spermaticus. 

Art.  femoralis. 

"S'ena  femoralis. 

I^vmphog"landula. 

M.  sartorius. 


M.  cremastcr. 


Fig.  5. 


M.  rectus  abdominis. 


\i.  transversus.  — 


Ligamentum  iiisfuinale. 


Funiculus  spermaticus.  — 


Nerv.  femoralis. 
Art.  femoralis. 

\"ena  femoralis. 


M.  sartorius. 
M.  adductor  long-iis. 


MOUTH  OF  THE  HERNIA.  27 

The  next  deeper  layer  is  exposed  by  the  removal  of  the 
internal  oblique  end  of  the  anterior  lamella?  of  the  aponeu- 
roses (Fig.  5).  At  the  outer  side  is  the  transversalis, 
while  in  the  middle  is  seen  the  rectus  muscle  with  its  three 
tendinous  intersections.  The  rectus  has  a  broad  origin 
from  the  fifth,  sixth,  and  seventh  ribs  and  from  the  xiphoid 
process.  It  becomes  somewhat  narrower  as  it  passes 
downward,  sends  some  fibers  across  the  median  line  to  its 
fellow  of  the  opposite  side,  and  is  inserted  into  the  upper 
border  of  the  symphysis.  The  small  muscle  situated 
anterior  to  the  lower  end  of  the  rectus  and  in  the  same 
sheath  is  known  as  the  pyramidalis.  Its  fibers  pass  from 
below  upward  and  inward,  and  are  inserted  into  the  linea 
alba.  The  transversalis  muscle  arises  by  six  serrations 
from  the  inner  surface  of  the  six  lower  ribs,  from  the  lum- 
bar fascia,  from  the  crest  of  the  ilium,  and  from  Poupart's 
ligament.  These  muscular  fibers  also  terminate  in  a  broad 
aponeurosis  which  is  inserted  into  the  linea  alba,  the  upper 
three-fourths  passing  behind  the  rectus,  while  the  lower 
fourth  passes  in  front  of  this  muscle  (the  portion  of  the 
aponeurosis  forming  the  sheath  of  the  rectus  is  not  seen  in 
Fig.  5).  The  spermatic  cord  is  seen  lying  in  the  inguinal 
canal,  which  is  exposed  as  far  as  its  internal  orifice — the 
internal  abdominal  ring.  In  the  femoral  region  Scarpa's 
triangle  (bounded  by  Poupart's  ligament,  the  sartorius, 
and  the  adductor  longus)  has  been  dissected  out,  and  in  the 
space  between  the  femoral  vein  and  the  adductor  longus  is 
seen  a  portion  of  the  deep  fascia  covering  the  pectineus 
muscle. 

In  figure  6  the  rectus  muscle  has  been  removed  and  the 
posterior  portion  of  its  sheath  exposed.     This  sheath  ceases 


28  HERNIA. 

Fig.  6. — The  anterior  abdominal  wall  after  removal  of  the  rectus 
muscle:  The  posterior  layer  of  the  associated  aponeurosis  is  exposed, 
and  its  sharp  lower  border,  known  as  the  semilunar  fold  of  Douglas,  is 
also  seen.  The  background  of  the  space  below  the  semilunar  fold  is 
formed  by  the  transversal  is  fascia,  upon  the  surface  of  which  a  portion 
of  the  deep  epigastric  artery  is  observed.  The  greater  portion  of  the 
spermatic  cord  has  been  removed  and  enough  of  the  transversalis 
muscle  cut  away  to  expose  the  internal  abdominal  ring. 

In  the  femoral  region  the  fascia  lata  has  also  been  removed  from 
the  pectineus  muscle. 

abruptly  midway  between  the  umbilicus  and  the  symphysis, 
thus  forming  the  semilunar  fold  of  Douglas.  The  sper- 
matic cord  and  the  portion  of  fascia  covering  the  pectineus 
have  also  been  removed,  so  that  the  internal  abdominal 
ring  and  the  pectineus  muscle  are  plainly  visible.  The 
remaining  layers  of  the  anterior  abdominal  wall,  passing 
from  without  inward,  are  the  transversalis  fascia,  the  sub- 
peritoneal areolar  tissue,  and  the  parietal  peritoneum. 

Since  the  strength  of  the  anterior  abdominal  w^all  is 
actually  dependent  upon  the  arrangement  of  the  aponeuroses 
of  the  abdominal  muscles,  it  will  be  of  advantage  to  study 
particularly  those  portions  of  the  aponeuroses  which  form 
the  sheath  of  the  rectus. 

The  aponeurosis  of  the  external  oblique  is  a  single  layer 
and  covers  the  anterior  surface  of  the  rectus  muscle. 

The  aponeurosis  of  the  internal  oblique  divides  into  an 
anterior  and  a  posterior  layer :  the  anterior  layer  also 
covers  the  anterior  surface  of  the  rectus  muscle  and  fuses 
with  the  aponeurosis  of  the  external  oblique ;  the  posterior 
layer  passes  behind  the  rectus  nuiscle  and  its  inferior  mar- 
gin forms  the  semilunar  fold  of  Douglas  midway  between 
the  umbilicus  and  the  symphysis. 


Fifj.  G. 


M.  transversus. 

Linea  semicircularis  Douglasi. 
Art.  epigfastrica  inferior. 


M.  tensor  fasciae  latae.  -— 


Anniilus  inguin.   abdominalis. 

M.  rectus. 

M.  pyramidalis. 

Nerv.  femoralis. 

Art.  femoralis. 

Vena  femoralis. 

Funiculus  spermaticus. 

M.  pectineus. 


M.  quadriceps.  - 
M.  adductor  long-us. 


MOUTH  OF  THE  HERNIA.  29 

The  aponeurosis  of  the  transversalis  muscle  is  a  single 
layer  which  passes  behind  the  rectus  muscle  as  far  down  as 
the  semilunar  fold  of  Douglas,  fusing  with  the  posterior 
layer  of  the  aponeurosis  of  the  internal  oblique.  Below 
the  semilunar  fold  of  Douglas  the  aponeurosis  of  the  trans- 
versalis passes  in  front  of  the  rectus  muscle. 

From  this  description  it  will  be  seen  that  the  posterior 
surface  of  the  inferior  portion  of  the  rectus  is  covered  by  no 
aponeurosis  whatever,  and  that  this  portion  of  the  abdomi- 
nal wall  is  particularly  weak,  since  the  rectus  muscle  lies 
directly  upon  the  transversalis  fascia  and  peritoneum.  In 
addition  to  this,  there  is  a  space  at  the  outer  side  of  the 
rectus  which  has  no  muscular  covering,  so  that  with 
advancing  years  and  relaxation  of  the  abdominal  wall,  a 
hernia — the  so-called  internal  inguinal  hernia — can  easily 
protrude  through  this  portion  of  the  abdominal  parietes. 

A  glance  at  the  interior  of  the  pelvis  (Fig.  7)  will  reveal 
the  positions  and  relations  of  the  most  important  hernial 
orifices.  The  figure  represents  a  sagittal  section  through 
the  median  line  of  the  lumbar  vertebrae  and  the  right  hori- 
zontal ramus  of  the  pubis  at  the  level  of  the  pubic  spine. 
The  peritoneum  has  been  removed  and  the  anterior  abdom- 
inal Avail  is  put  upon  the  stretch  by  means  of  a  tenaculum. 
The  bladder  is  situated  beyond  the  symphysis,  and  more 
posteriorly  the  stump  of  the  rectum  is  observed.  Pou- 
part's  ligament  can  be  seen  through  the  structures  of  the 
anterior  abdominal  wall,  and  the  point  at  which  the  exter- 
nal inguinal  hernia  passes  out  from  the  abdomen  is  indi- 
cated by  the  junction  of  the  spermatic  artery  and  the  vas 
deferens.  For  the  sake  of  clearness  the  spermatic  artery 
has  been  placed  above  the  common  iliac.    Somewhat  nearer 


30  HERNIA. 

Fig.  7. — A  sagittal  section  through  the  middle  of  the  spinal  column 
and  the  right  horizontal  ramus  of  the  pubis,  exposing  the  interior  of 
the  pelvis  :  a,  Kectus  abdominis  muscle  ;  b,  deep  epigastric  artery  ; 
c,  vas  deferens  ;  d,  spermatic  artery  ;  e,  external  iliac  artery  ;  f,  exter- 
nal iliac  vein  ;  g,  oliturator  vessels  and  nerve  ;  h,  superior  gluteal 
artery  ;  i,  urinary  bladder  ;  k,  rectum. 

to  the  median  line  the  deep  epigastric  artery  is  seen 
passing  upward  along  the  anterior  abdominal  wall,  and  it 
is  between  this  artery  and  the  border  of  the  rectus  muscle 
that  the  internal  (or  direct)  inguinal  hernia  protrudes. 
The  external  iliac  artery  and  vein  pass  anteriorly  beneath 
Poupart's  ligament,  and  just  alongside  of  the  vein  the 
drawing  shows  a  small  lymphatic  gland  which  marks  the 
point  of  exit  of  the  femoral  hernia.  Within  the  true 
pelvis  the  obturator  artery  is  seen  to  arise  from  the  superior 
gluteal,  although  this  vessel  is  usually  given  off  by  one  of 
the  divisions  of  the  internal  iliac.  The  obturator  artery, 
accompanied  by  two  veins  and  a  nerve  of  the  same  name, 
passes  anteriorly  and  indicates  the  situation  of  the  mouth 
of  an  obturator  hernia.  The  superior  gluteal  artery  passes 
posteriorly  with  a  sharp  turn  and  penetrates  the  deeper 
tissues  just  above  the  sacral  plexus.  The  sciatic  artery, 
which  leaves  the  pelvis  below  the  sacral  plexus,  has  been 
cut  off  so  that  only  its  stump  is  visible.  The  sciatic  her- 
nia passes  out  of  the  abdominal  cavity  along  the  course  of 
the  superior  gluteal  or  of  the  sciatic  artery. 

The  other  boundaries  of  the  abdominal  cavity — the 
diaphragm,  the  pelvic  floor,  and  the  musculature  of  the 
back — also  have  spaces  between  individual  groups  of  mus- 
cles through  which  it  is  possible  for  a  peritoneal  divertic- 
ulum to  protrude.     These  hernias  are  nevertheless  very 


Fig.  7. 


«>'     \ 

■        c 

IP'A       ^    ■ 

=.-          -_  d 

W  \^Jk 

=-,_              _  t; 

.jt^^y^y^ 

_     f 

0^ /^ 

.i^M 

" '  y~ 

SAC.  31 

rare,  and  wc  will   defer  the   description  of  such   hernial 
orifices  until  we  consider  sj^ecial  hernias. 

The  sac  of  the  hernia  is  that  portion  of  the  peritoneum 
which  protrudes  through  the  hernial  orifice,  and  in  its 
unchanged  condition  consists  of  a  very  thin  transparent 
lamella.  A  case  in  which  the  abdominal  viscera  protrude 
through  the  abdominal  wall  without  any  cutaneous  or  per- 
itoneal covering  (as  after  a  punctured  wound  of  the  abdo- 
men, for  example)  is  not  designated  as  a  hernia  but  as  a 
prolapse.  In  certain  cases  of  congenital  fissure  of  the 
diaphragm  (see  Fig.  102)  the  intestines  may  pass  into  the 
pleural  cavity  without  a  peritoneal  covering,  and  custom 
has  designated  these  cases  as  hernias,  although,  accurately 
speaking,  this  use  of  the  word  is  incorrect.  A  yielding 
abdominal  scar  may  allow  the  intestines  to  protrude,  and  it 
is  also  customary  to  refer  to  this  condition  as  a  ventral 
hernia,  although  the  hernial  sac  is  frequently  wanting  and 
its  place  taken  by  scar  tissue.  The  hernias  of  the  urinary 
bladder  and  of  the  ascending  and  descending  colon  make 
an  apparent  exception  to  the  general  rule  that  every  hernia 
must  have  a  sac.  Since  these  structures  have  only  a  par- 
tial peritoneal  covering,  and  consequently  are  only  partly 
within  the  abdomen,  it  can  happen  that  the  portion  which 
protrudes  may  have  no  peritoneal  covering.  In  this  case, 
however,  the  sac  is  somewhat  higher  up,  so  that  the  viscus 
constituting  the  contents  of  the  hernia  lies  partly  within 
and  partly  without  the  sac. 

The  hernial  sac  may  be  congenital,  all  of  its  parts  being 
present  at  birth,  although  this  is  only  possible  in  certain 
situations  which  are  so  predisposed  for  developmental 
reasons.     It  frequently  happens  that  the  hernial  sac  is  first 


32  HERNIA. 

formed  during  extra-uterine  life  by  the  influence  of  the  so- 
called  ''abdominal  tension '';  i.  e.,  by  a  sudden  increase  of 
the  intra-abdominal  pressure,  as  in  coughing,  crying,  sneez- 
ing, vomiting,  straining  at  stool,  or  the  lifting  of  heavy 
loads,  or  by  traction  from  without  from  the  growth  of  a 
subperitoneal  lipoma. 

At  this  place  it  may  be  emphasized  that  the  complete 
protrusion  of  the  peritoneum  into  a  hernial  sac  never  occurs 
from  a  single  augmentation  of  the  intra-abdominal  tension, 
however  great  it  may  be  ;  such  a  protrusion  always  occurs 
slowly  as  the  result  of  the  repeated  eifect  of  some  of  the 
influences  just  mentioned.  It  is  partly  due  to  a  yielding 
of  the  peritoneum,  but  the  most  important  factor  is  a  loose- 
ning of  that  portion  of  the  peritoneum  about  the  internal 
ring  and  its  protrusion  through  the  hernial  orifice.  Evi- 
dence of  this  is  frequently  furnished  by  the  radiating  folds 
of  the  peritoneum.  If  a  hernial  tumor  suddenly  makes 
its  appearance  during  a  marked  increase  of  the  intra-abdo- 
minal tension,  in  an  individual  who  has  previously  pre- 
sented no  sign  of  hernia, — and  these  are  the  cases  which 
formerly  led  to  the  supposition  of  a  rupture  of  the  peri- 
toneum,— we  may  be  sure  that  the  hernial  sac  was  either 
congenital  or  gradually  formed  during  some  period  of 
extra-uterine  life. 

The  portion  of  the  sac  situated  within  the  hernial  orifice 
is  known  as  the  neck,  the  main  portion  of  the  protrusion 
is  called  the  body,  and  the  lowest  part  of  the  sac  is  desig- 
nated the  fundus. 

In  small  and  moderately  large  hernias  the  sac  has  cer- 
tain characteristics  wliich  naturally  become  obliterated  if 
the  hernia  increases  in  size.     The  sac  of  an  umbilical  her- 


SAC.  33 

Ilia  tends  to  assume  a  spherieal  shape,  wliilc  that  of  a 
femoral  hernia  is  more  ovoid.  Aeeording  to  Bayer,  a  con- 
genital inguinal  hernia  usually  has  a  pear-shaped  sac  with 
a  narrow  neek  and  a  broad  fundus,  while  the  sac  of  an 
acquired  inguinal  hernia  has  a  wide  mouth  from  the  very 
beginning. 

The  sac-wall,  like  the  peritoneum,  is  a  thin  connective- 
tissue  membrane  which  is  rich  in  elastic  fibers,  but  sparingly 
traversed  by  blood-vessels  and  nerves,  wdiich  is  lined  with 
squamous  epithelial  cells,  and  which  always  presents  a 
smooth,  moist,  glistening  surface.  If  such  peritoneal  sur- 
faces are  exposed  to  any  irritation,  such  as  pressure,  circu- 
latory disturbances,  or  inflammation,  thev  become  adherent 
or  form  exudates  and  inflammatory  deposits.  It  conse- 
quently happens  that  we  occasionally  see  irregular  thicken- 
ings in  hernial  sacs,  particularly  in  those  cases  in  which 
folds  have  been  formed  in  intra-uterine  or  in  extra-uterine 
life.  If  such  a  thickening  runs  around  the  sac  in  a  circu- 
lar direction,  an  hour-glass  constriction  may  be  produced 
(Fig.  8)  ;  if  a  number  of  these  circular  constrictions  are 
present,  the  hernial  sac  may  resemble  a  string  of  beads. 
Such  configurations  are  more  frequently  caused  by  the 
loosening  of  the  tissues  about  the  thickened  neck  of  the 
sac,  wdiich  is  produced  by  the  traction  of  the  herniated  vis- 
cera with  every  increase  of  the  intra-abdominal  pressure ; 
the  adjacent  peritoneum  is  drawn  into  the  hernial  orifice 
and  the  entire  sac  descends.  If  a  number  of  thickenings 
of  the  sac-wall  are  present,  the  intermediate  portions  of  the 
sac  may  yield  from  the  intermittent  augmentations  of  the 
intra-abdominal  tension,  and  diverticula  are  easily  pro- 
duced (Fig.  9). 
3 


34 


HERNIA. 


Fig.  9. — A  hernial  sac  with 
four  diverticula  :  This  specimen 
was  removed  at  an  operation  upon 
a  strangulated  femoral  hernia. 
The  diverticula  contained  nothing 
but  fluid ;  the  remaining  portion 
of  the  sac  was  filled  with  omen- 
tum. 


Fig.  8. — Hour-glass  constriction  of  a  hernial  sac:  This  specimen 
was  extirpated  at  a  radical  operation  for  inguinal  hernia,  and  contained 
a  large  piece  of  omentum  which  had  become  adherent  to  the  sac  at  the 
seat  of  constriction. 


CONTENTS.  35 

111  the  great  inajority  of  cases  the  contents  of  the 
hernia  consist  of  portions  of  the  small  intestine,  or  por- 
tions of  the  omentum,  or  of  both.  This  is  because  these 
structures  are  the  most  movable  and  the  most  susceptible 
to  dislocation.  Next  in  order  come  the  colon  and  the 
cecum,  either  with  or  without  the  vermiform  appendix, 
and  the  latter  structure  may  be  found  alone.  In  a  general 
way,  it  may  ])e  said  that  there  is  scarcely  an  abdominal 
organ  that  has  not  been  found  in  a  hernia,  since  the  stom- 
ach, liver,  pancreas,  ovaries,  tubes,  uterus,  bladder,  kidney, 
and  spleen  have  all  been  observed  within  a  hernial  sac. 
In  addition  to  any  of  these  structures,  and  particularly  if 
circulatory  disturbances  or  inflammation  have  occurred, 
there  is  present  a  collection  of  water  which  is  known  as 
the  hernial  fluid.  There  are  certain  organs  which  can  pass 
into  the  sac  of  a  hernia  only  when  their  fixation  in  the 
peritoneal  cavity  is  looser  than  normal.  Certain  portions 
of  the  colon,  for  example,  may  possess  such  a  long  meso- 
colon that  they  may  easily  descend  as  low  as  the  inguinal 
region  and  protrude  into  an  inguinal  hernia.  Such  a  relaxa- 
tion of  attachments  may  also  be  acquired,  since  the  abdom- 
inal organs  may  descend  as  the  result  of  a  general  splanch- 
noptosis, or  individual  organs  may  be  drawn  down  by  the 
peritoneum  and  some  adjacent  viscus  which  is  more  mov- 
able. 

The  size  of  a  hernia  is  principally  dependent  upon  the 
amount  of  its  contents,  and  is  subject  to  the  greatest  pos- 
sible variation.  A  small  piece  of  omentum  will  produce 
a  swelling  that  is  scarcely  visible  externally,  Avhile  an 
inguinal  hernia  may  contain  almost  all  of  the  abdominal 
organs  and  form  a  large  sac  extending  as  low  down  as  the 


36  HERNIA. 

Fig.  10. — Diagrammatic  representation  of  a  hernia  of  the  intestinal 
wall. 

Fig.  11. — Diagrammatic  rei^resentation  of  a  hernia  of  a  divertic- 
ulum. 

knee.  The  latter  condition  is  known  as  eventration,  and 
if  it  exists  for  some  time,  it  is  frequently  impossible  to 
replace  the  viscera,  since  the  abdominal  cavity  has  become 
correspondingly  contracted. 

If  the  contents  of  a  hernial  sac  consist  of  an  intestinal 
loop,  that  portion  of  the  intestine  situated  on  the  proximal 
side  of  the  hernia  is  known  as  the  afferent  intestine,  while 
that  portion  on  the  distal  side  is  known  as  the  efferent 
intestine.  An  entire  intestinal  coil  does  not  always  pro- 
trude, however,  and  it  not  infrequently  happens  that  only 
the  intestinal  wall  opposite  the  insertion  of  the  mesentery 
is  found  within  the  sac,  so  that  a  pouching  of  the  intes- 
tinal wall  is  produced  (Fig.  10).  Such  cases  are  known 
as  hernia  of  the  intestinal  wall.  A  similar  condition  is 
observed  when  a  Meckel's  diverticulum  enters  a  hernial 
sac.  This  diverticulum  is  the  remains  of  the  omphalo- 
enteric  duct  of  fetal  life,  and  is  usually  found  from  one- 
half  to  one  meter  above  the  ileocecal  valve  (see  "  Umbilical 
Hernia,"  page  208).  This  hernia  of  a  congenital  diver- 
ticulum (Fig.  11)  was  first  described  by  Littre,  and  is  con- 
sequently called  Littre' s  hernia  by  many,  although  the 
same  name  is  usually  also  employed  in  reference  to  the 
ordinary  hernia  of  the  intestinal  wall. 

There  are  also  acquired  intestinal  diverticula  (Fig.  12) 
which  may  occupy  a  hernial  sac.  They  may  develop  in 
any  portion  of  the  intestinal  canal,  are  usually  multiple, 
and  are  formed  by  a  protrusion  of  the  mucous  membrane 


y 


CONTENTS.  37 

through  an  opening  in  the  muscular  coat  of  the  bowel.  It 
consequently  follows  that  while  the  congenital  diverticulum 
of  Meckel  (Fig.  13)  contains  all  the  layers  of  the  normal 
intestinal  wall,  the  acquired  diverticulum  consists  of  the 
serosa  and  mucosa  and  of  but  a  few  fibers  from  the  longi- 
tudinal muscular  coat  of  the  bowel. 

In  order  to  appreciate  the  special  characteristics  of  the 


Fig.  12. — Acquired  intestinal  diverticula  (from  Schmidt). 

contents  of  any  hernia,  it  will  be  appropriate  to  separately 
consider  the  individual  organs  which  have  been  observed 
in  hernias,  and  they  will  be  taken  up  in  the  order  which 
corresponds  to  the  frequency  of  their  occurrence. 

The  small  intestine  has  the  longest  mesentery  of  any 
abdominal  organ,  and  is  consequently  the  one  most  likely 
to  descend  into  a  hernial  sac.     Approximately  speaking, 


38 


HERNIA. 


the  upper  three-fifths  of  the  small  intestine  are  known  as 
the  jejunum,  while  the  lower  two-fifths  are  called  the  ileum. 
The  distance  from  the  line  of  insertion  of  the  mesentery 
at  the  posterior  abdominal  wall  to  the  intestine  is  greatest 
at  about  25  centimeters  above  the  appendix,  and  in  this 
situation  is  about  23  centimeters.     This  distance  becomes 


Fig.  13. — A  long  Meckel's  diverticulum  of  the  small  intestine. 

much  shorter  both  toward  the  duodenum  and  toward  the 
cecum — 11  to  13  centimeters.  From  this  may  be  seen 
which  portion  of  the  intestinal  canal  is  particularly  predis- 
posed to  form  the  contents  of  a  hernia,  and  also  that  the 
passage  of  an  intestine  into  a  hernial  sac  is  so  dependent 
upon  the  condition  of  its  mesentery  that  with  every  descent 


CONTENTS,  39 

of  the  hernia  it  is  highly  probable  that  one  and  the  same 
intestinal  coil  protrudes  through  the  hernial  orifice. 

The  Omentum. — In  283  inguinal  hernias,  Maydl  has 
found  the  omentum  as  the  sole  contents  77  times,  and 
omentum  together  with  the  intestines  34  times;  in  123 
femoral  hernias  he  found  omentum  alone  19  times,  and  in 
combination  with  the  intestine  14  times.  If  both  omen- 
tum and  intestine  are  contained  in  the  same  hernia,  the 
omentum  usually  retains  its  relative  position  and  is  situated 
in  front  of  the  intestinal  coil.  If  the  omentum  remains 
in  the  sac  for  some  time,  it  frequently  undergoes  certain 
changes.  The  opposed  omental  surfaces  may  grow  together, 
forming  irregular  masses,  or  the  fatty  tissue  of  the  omen- 
tum may  take  on  a  lipomatous  thickening.  Adhesions  are 
very  easily  formed  between  the  omentum  and  the  wall  of 
the  sac,  and  it  is  usually  the  lowest  tip  of  the  omentum 
that  grows  fast  to  the  sac.  This  is  not  always  so,  how- 
ever, since  in  some  rare  cases  a  certain  portion  of  the  sur- 
face of  the  omentum  may  adhere  to  the  fundus  of  the  sac 
and  the  free  end  turn  upon  itself  and  pass  back  into  the 
abdominal  cavity  (Fig.  14).  If  such  a  condition  is  not 
recognized  at  the  time  of  operation,  the  customary  ligation 
of  the  omentum  in  sections  may  be  followed  by  bad  results, 
since  such  an  omental  process,  being  cut  off  from  all  of 
its  connections,  falls  into  the  peritoneal  cavity,  becomes 
necrotic,  and  thus  favors  the  development  of  a  purulent 
peritonitis. 

The  Large  Intestine. — The  sigmoid  and  the  transverse 
colon  possess  rather  long  mesenteries,  which  are,  how- 
ever, subject  to  great  variations  in  this  respect.  The  as- 
cending and  the  descending  colon  have  no  free  mesentery; 


40  HERNIA. 

their   posterior   surfaces   are   adherent   to   the    posterior 


Fig.  14. — A  hernial  sac  containing  adherent  omentnm,  the  tip  of 
which  has  turned  upon  itself  and  passed  back  into  the  abdomen.  The 
omentum  has  been  tied  off  by  three  ligatures,  and,  at  the  point  of  liga- 
tion furthest  to  the  right,  the  recurrent  tip  of  omentum  (a)  may  be  seen 
projecting  into  the  peritoneal  cavity.  ( Diagrammatic  drawing  based 
upon  a  case  operated  upon  at  the  Surgical  Clinic  of  Gottingen. ) 

abdominal  wall  and  are  consequently  uncovered  by  peri- 
toneum.      Under   certain    circumstances,  however,  these 


CONTENTS.  41 

viscera  are  not  so  firmly  adherent,  and  then  even  these 
portions  of  the  intestinal  tract  have  a  certain  range  of  mo- 
tion. The  peritoneal  covering  of  the  cecum  at  its  point 
of  reflection  upon  the  ascending  colon  shows  a  similar 
arrangement ;  /.  c.^  the  posterior  surface  of  the  cecum  is 
extraperitoneal,  while  the  cecum  itself  and  the  vermiform 
process  are  surrounded  by  peritoneum.  [The  cecum  is 
frequently  so  movable  that  the  appendix  may  be  found  in 
a  left  inguinal  hernia.  I  have  observed  one  such  case  and 
a  number  have  been  reported. — Ed.] 

From  this  description  may  be  seen  the  relative  ability 
of  the  different  portions  of  the  large  intestine  to  descend 
into  a  hernial  sac.  It  is  also  to  be  remembered  that  the 
mobility  of  the  transverse  colon  is  limited  by  its  connec- 
tion with  the  more  finnly  fixed  ascending  and  descending 
colons,  and  that  the  cecum  can  be  more  easily  dislocated 
by  the  adjacent  and  more  freely  movable  ileum.  It  con- 
sequently happens  that  the  cecum,  the  transverse  colon, 
and  the  sigmoid  flexure  can  pass  into  a  hernial  sac  much 
more  easily  than  the  ascending  and  descending  colons.  In 
no  small  number  of  cases  the  vermiform  appendix,  either 
alone  or  with  the  cecum,  is  found  as  the  contents  of  a  her- 
nia, and  sometimes  becomes  inflamed  within  the  hernial  sac. 

[In  32  cases  of  cecal  hernia  operated  upon  by  the  \mter 
the  appendix  was  also  found  in  the  hernial  sac  eight  times. 
In  two  of  these  cases  the  hernia  was  strangulated. — Ed.] 

When  those  portions  of  the  large  intestine  which  have 
only  a  partial  peritoneal  covering  pass  into  a  hernia,  they 
maintain  the  same  relations  to  the  peritoneum  ;  i.  c,  they 
lie  partly  within  and  partly  without  the  hernial  sac,  as  has 
previously  been  mentioned. 


42  HERNIA. 

With  the  exception  of  umbihcal  hernia,  and  in  accord- 
ance with  the  usual  k)cation  of  the  abdominal  viscera, 
hernia  of  the  cecum  and  of  the  ascending  colon  are  more 
frequent  upon  the  right  side,  whereas  those  of  the  sigmoid 
and  descending  colon  are  more  commonly  observed  upon 
the  left.  The  opposite  condition  may,  however,  obtain, 
and  it  is  then  fair  to  assume  the  existence  of  a  congenital 
displacement  of  the  viscera.  At  an  early  stage  of  develo]>- 
ment  both  the  ascending  and  descending  mesocolons  are 
as  freely  movable  as  is  the  mesentery  of  the  small  intes- 
tine, and  at  a  later  period  they  become  closely  attached  to 
the  parietal  peritoneum  of  the  posterior  abdominal  wall. 
If  the  mesocolon  remains  long  and  movable  instead  of 
passing  through  the  usual  developmental  changes,  the  ap- 
pearance of  the  cecum  in  a  left-sided  inguinal  or  femoral 
hernia  may  be  easily  understood.  In  a  similar  manner  if 
the  sigmoid  flexure  is  found  in  a  right-sided  hernia,  we  are 
forced  to  assume  that  it  has  a  congenitally  long  mesentery. 
It  goes  without  saying  that,  in  addition  to  the  large  intes- 
tine, both  omentum  and  coils  of  the  small  intestine  may  be 
found  in  the  hernial  sac. 

No  other  organs  except  those  just  mentioned  are  com- 
monly found  as  the  contents  of  a  hernia.  It  is  true  that 
in  1898  Brunner  was  able  to  collect  180  cases  of  vesical 
hernia  from  the  literature,  but  these  cases  were  those  occur- 
ring within  a  period  of  about  a  hundred  years,  and  their 
number  is  not  so  great  when  compared  with  the  enormous 
number  of  operations  for  hernia  which  have  been  performed 
in  the  last  decennium  as  a  result  of  the  modern  methods 
of  asepsis  and  of  the  development  of  the  technic  of  the 
operation  for  radical  cure.     [Of  950  cases  of  inguinal  and 


CONTENTS.  43 

femoral  hernia  operated  upon  T  have  not  observed  a  single 
hernia  of  the  bladder. — Ed.] 

From  the  fact  that  only  the  upper  and  a  part  of  the 
posterior  surface  of  the  bladder  is  covered  by  peritoneum, 
it  will  be  seen  that  either  the  intraperitoneal  or  the  extra- 
peritoneal portion  of  this  organ  may  pass  into  a  hernia. 
According  to  B runner,  it  most  frequently  happens  that  the 
uncovered  portion  of  the  bladder  is  the  first  to  protrude 
through  a  hernial  orifice,  and  that  this  is  followed  by  a  sac 
of  peritoneum.  It  must  also  be  remembered  that  a  vesical 
hernia  may  be  simulated  during  an  operation  upon  an  in- 
guinal hernia  if  strong  traction  is  made  upon  the  isolated 
sac.  Under  such  circumstances  the  bladder  is  sometimes 
drawn  down  with  the  hernia,  but  it  sinks  back  into  its 
normal  position  when  the  traction  is  discontinued.  It  not 
infrequently  happens  that  the  presence  of  a  vesical  hernia 
is  not  suspected  until  the  bladder  is  cut  into  at  the  time 
of  operation.  To  avoid  the  occurrence  of  such  an  accident, 
the  anamnesis  should  be  carefully  studied  for  the  pre-exist- 
ence  of  vesical  symptoms  and  a  catheter  should  be  intro- 
duced to  determine  the  relation  of  the  bladder  to  the  hernial 
contents.  During  the  operation  the  presence  of  the  bladder 
is  frequently  indicated  by  a  marked  increase  in  the  amount 
of  the  prevesical  areolar  tissue. 

The  publications  in  reference  to  hernia  of  the  ovaries 
Avere  last  collected  in  1878  by  Puech.  He  was  able  to 
find  86  cases,  of  which  the  greater  portion  (54)  must  be 
regarded  as  congenital.  Both  ovaries  have  been  repeatedly 
found  in  bilateral  hernias.  English  collected  9  such  cases 
of  bilateral  inguinal  hernia,  Otte  found  a  similar  condition 
in  a  bilateral  femoral  hernia,  and  in  one  of  the  cases  col- 


44  HERNIA. 

lected  by  Puech  one  ovary  was  in  a  sciatic  hernia  while 
the  other  was  situated  in  an  uni})ilical  hernia.  The  char- 
acteristic symptoms  of  a  hernia  of  the  ovary  are  a  typi- 
cal pain  upon  pressure,  analogous  to  that  produced  by 
pressing  upon  the  testicle,  and  a  periodic  swelling  of  the 
hernia  appearing  simultaneously  with  menstruation.  The 
latter  and  more  important  symptom  is,  of  course,  absent  in 
children  and   in  women  who  have  passed  the  menopause. 

The  Fallopian  tubes,  rarely  alone  but  more  frequently 
with  the  ovaries,  have  been  found  in  both  inguinal  and 
femoral  hernia. 

Maydl  states  that,  up  to  the  present  time,  the  uterus  has 
bedn  found  seventeen  times  as  the  contents  of  a  hernia. 
In  nine  cases  the  uterus,  the  ovaries,  and  the  tubes  were 
present,  and  in  two  of  these  intestinal  coils  were  also 
observed  within  the  hernial  sac ;  in  five  cases  the  uterus 
showed  evidence  of  developmental  anomalies,  and  in  sev- 
eral instances  it  was  in  a  pregnant  condition.  According 
to  Gurlt,  the  latter  state  of  affairs  gave  the  surgeon, 
Trautmann,  an  opportunity  to  successfully  perform  a 
Caesarian  section  in  1610,  both  mother  and  child  being 
saved. 

The  stomach  has  been"observed  not  only  in  diaphragma- 
tic and  umbilical,  but  even  in  inguinal  and  femoral  hernia. 
On  account  of  the  frequent  occurrence  of  gastric  pain  in  cases 
of  epigastric  hernia,  it  was  formerly  supposed  that  these 
hernias  were  particularly  likely  to  contain  a  part  of  the 
stomach.  Since  we  now  know  that  traction  upon  the 
omentum  may  cause  such  gastric  pains,  or  that  they  may 
even  result  reflexly  from  traction  upon  the  parietal  peri- 
toneum, we  should  designate  only  those  cases  as  gastric 


COVERINGS.  45 

hernia  in  which  the  presence  of  the  stomach  within  the 
hernial  sac  has  been  incontrovertibly  proved. 

The  microscopic  examination  of  small  fistulas,  C3''sts,  and 
tumors  of  the  umbilicus  which  sometimes  remain  as  rests 
of  the  omphalo-enteric  duct  has  repeatedly  demonstrated 
the  existence  of  a  nnicous  membrane,  the  structure  of 
which  resembled  that  of  the  stomach.  In  one  instance  the 
mucous  membrane  even  furnished  a  secretion  which  pos- 
sessed certain  digestive  properties.  Tillmanns,  who  de- 
scribed the  first  case  of  this  kind,  thought  that  originally 
a  small  gastric  diverticulum  had  been  present  in  a  con- 
genital umbilical  hernia,  that  this  diverticulum  had  be- 
come walled  off  from  the  stomach,  and  that  it  had  protruded 
externally  after  the  separation  of  the  cord  had  taken  place. 
This  case,  Avhich  the  newer  works  still  classify  with  gastric 
hernias,  has  nevertheless  nothing  to  do  with  them,  and 
should  be  considered  as  a  developmental  anomaly  of  the 
omphalo-enteric  duct  (Ophiils). 

The  liver  has  been  found  in  diaphragmatic  and  in  con- 
genital umbilical  hernias.  In  the  latter  position  it  has 
sometimes  formed  the  sole  contents  of  the  hernial  sac. 

The  dilated  gall-bladder  was  found  alone  in  a  hernia 
of  the  linea  alba  by  Lanz  and  in  an  inguinal  hernia  by 
Skey. 

As  instances  of  rare  contents  of  an  inguinal  hernia  may 
be  mentioned  a  floating  kidney  (Deipser),  a  dilated  ureter 
(Reichel),  and  the  spleen  (Ruysch).  The  pancreas  has 
been  found  in  an  umbilical  hernia  (Rose),  and  a  testicle 
which  failed  to  descend  into  the  scrotum  has  been  observed 
in  a  femoral  hernia  (Guincourt). 

The  coverings  of  a  hernia  (Fig.  15)  are  those  layers 
of  tissue  which  inclose  the  hernial  sac.  The  hernial  ori- 
fices are  not  naturally  patulous,  but  are  closed  by  loose 


46  HERNIA. 

Fig.  15. — A  diagrammatic  rej)reseutation  of  the  coverings  of  a  her- 
nia: a,  The  skin;  b,  the  superficial  fascia;  c,  the  muscular  layer — e.  g.^ 
the  cremaster  muscle  in  an  inguinal  hernia;  d,  the  transversalis  fascia; 
c,  d,  have  also  been  called  the  fascia  propria  hernia3;  e,  the  peritoneum 
—  i.  €. ,  the  sac  of  the  hernia. 


connective  tissue,  fascias,  tendons,  or  muscles,  and  filled  up 
by  vessels  making  their  exit  from  the  abdomen.  When  a 
hernial  sac  commences  to  descend,  the  tissues  in  front  of 
it  are  either  pushed  to  one  side  or  forced  in  advance  of  the 
hernia.  The  protruded  structures  form  the  coverings  of 
the  hernial  sac,  and  their  number,  character,  and  thick- 
ness vary  with  the  anatomic  peculiarities  of  the  location 
involved.  If  the  parietal  peritoneum  is  separated  from 
the  inner  surface  of  the  abdominal  wall,  it  will  be  seen 
that  the  entire  abdomen  is  lined  by  a  fascia  which  is  known 
as  the  intra-abdominal  fascia.  The  vessels  are  always 
situated  between  this  fascia  and  the  parietal  peritoneum, 
and  in  those  situations  in  which  the  vessels  pass  out  of  the 
abdomen  there  is  always  an  opening  in  the  fascia.  This 
opening  is  not  an  orifice  with  a  free  border,  but  is  formed 
by  the  fascia  passing  out  with  the  vessel  for  a  certain  dis- 
tance and  then  becoming  adherent  to  its  wall.  The  various 
portions  of  this  intra-abdominal  fascia  are  known  by  dif- 
ferent names  in  the  different  regions  of  the  abdomen. 
Upon  the  posterior  abdominal  wall,  where  it  partly  covers 
the  iliac  muscle,  it  is  known  as  the  iliac  fascia  ;  upon  the 
anterior  and  lateral  abdominal  walls,  where  it  lines  the 
transversalis  muscle  and  aponeurosis,  it  is  called  the  trans- 
versalis fascia,  and  within  the  pelvis  it  is  spoken  of  as  the 
pelvic  fascia.  The  particular  relation  of  this  fascia  to  any 
individual  hernia  will  be  fully  considered  in  the  section 


Fig.  lo. 


SUBPERITONEAL  LIP03IAS.  47 

upon  special  hernias,  and  at  this  place  it  will  be  sufficient 
to  emphasize  tlie  fact  that  this  fascia  always  exists  as  one 
of  the  coverings  in  any  variety  of  hernia.  In  accordance 
with  the  teaching  of  Cooper,  wlio  first  described  it  in  fem- 
oral hernia,  this  fascia,  alone  or  together  with  a  layer  of 
muscular  fibers,  is  called  the  fascia  propria,  or  the  fascia 
Cooperi.  However  interesting  the  relations  of  the  various 
hernial  coverings  may  be  from  an  anatomic  standpoint, 
they  are  of  little  practical  value,  and  any  one  who  operates 
upon  a  hernia,  and  who  attempts  to  use  his  anatomic 
knowledge  to  recognize  all  these  layers  as  he  cuts  through 
them,  wall  soon  find  that  such  a  course  is  almost  impossi- 
ble. In  certain  situations  these  coverings  are  unusually 
thin  and  difficult  of  recognition  ;  in  others  they  may  be 
fused  together,  and  if  the  hernia  is  old,  they  are  greatly 
thickened. 

SUBPERITONEAL  LIPOMAS* 

The  space  between  the  intra-abdominal  fascia  and  the 
parietal  peritoneum  contains  all  the  vessels  which  leave  the 
abdominal  cavity,  and  a  loose  connective  tissue,  more  or 
less  rich  in  fat,  which  in  certain  places  in  the  abdominal 
wall  may  proliferate  and  form  lipomas  of  considerable  size. 
These  are  called  subperitoneal,  preperitoneal,  or  subserous 
lipomas,  and  have  also  been  referred  to  as  '^  fat  hernias '' 
and  as  "  apparent  hernias.'^  They  have  been  mistaken  for 
true  abdominal  hernias,  and  must  be  discussed  in  connec- 
tion with  them,  since  the  two  conditions  frequently  coexist, 
and  in  certain  cases  it  is  fair  to  assume  that  the  lipoma 
holds  a  causal  relation  to  the  hernia. 

In  the  vicinity  of  certain  hernial  orifices — for  example, 


48  HERNIA. 

to  the  inner  side  of  the  femoral  vein  and  in  the  linea  alba 
— this  subperitoneal  areolar  tissue  is  markedly  developed, 
and  in  these  situations  favors  not  only  an  increased  mobil- 
ity of  the  parietal  peritoneum,  but  also  the  formation  of 
lipomas  (Fig.  16).  The  points  of  similarity  between  sub- 
peritoneal lipomas  and  abdominal  hernia  may  be  stated 
as  follows:  (1)  They  are  fonnd  in  the  common  hernial 
orifices,  the  femoral,  the  inguinal,  and  the  umbilical 
regions,  and  particularly  in  the  linea  alba ;  (2)  they  fre- 
quently become  more  protuberant  with  any  increase  of  the 
intra-abdominal  pressure,  such  as  that  produced  by  cough- 
ing, and  may  be  partly  or  wholly  replaced  ;  (3)  they  fre- 
quently produce  symptoms  which  are  similar  to  those  of 
abdominal  hernia.  These  symptoms  are  actually  due  to 
the  traction  of  the  lipoma  upon  the  adherent  parietal  peri- 
toneum, since  this  in  itself  is  sufficient  to  produce  pain. 
We  have  an  opportunity  of  observing  this  in  laparotomies 
done  under  Schleich's  anesthesia,  in  which  the  parietal 
peritoneum  usually  remains  exquisitely  sensitive  to  the 
slightest  traction  in  spite  of  the  most  successful  anesthesia. 
This  irritation  of  the  peritoneum  produces  a  reflex  pain 
wliich  is  usually  localized  in  the  gastric  region. 

The  traction  upon  the  peritoneum  may  occasionally  be 
so  marked  tliat  the  growing  lipoma  draws  the  peritoneum 
after  it,  and  thus  forms  a  hernial  sac.  If  a  tip  of  omen- 
tum is  adherent  to  this  sac, — a  not  infrequent  occurrence, 
— we  have,  in  addition  to  the  lipoma,  a  completely  devel- 
oped hernia  with  all  of  its  phenomena.  Subperitoneal 
lipomas  are  most  frequently  encountered  in  the  following 
situations,  which  are  named  in  the  order  of  their  frequency  : 
first,  the  linea  alba  or  its  immediate  vicinity,  and  almost 


SUBPERITONEAL  LIPOMAS. 


49 


Fig.  16. — Subperitoneal  lipoma  of  the  linea  alba  above  the  umbili- 
cus, viewed  from,  within:  This  figure  shows  the  inner  surface  of  the 
anterior  abdominal  wall.  Above  the  umbilicus,  which  may  be  recog- 
nized by  the  point  of  union  of  the  three  folds  passing  up  from  the 
bladder,  the  peritoneum  has  been  partly  dissected  up  and  thrown  back. 
A  small  subserous  lipoma  is  exposed,  the  small  pedicle  of  which  is 
seen  as  it  passes  forward  through  a  narrow  transverse  slit  in  the  linea 
alba.  From  the  picture  it  will  be  readily  understood  how  larger 
lipomatous  masses  may  be  forced  outward  by  any  augmentation  of  the 
intra-abdominal  tension,  and  how  it  might  be  possible  to  partially  re- 
place them,  as  may  sometimes  be  done  with  true  hernias. 


50  HERNIA. 

always  above  the  umbilicus ;  next,  in  the  femoral  region  ; 
and,  finally,  in  the  inguinal  and  umbilical  regions. 

AVhen  these  fatty  tumors  coexist  with  a  hernial  sac,  they 
have  an  additional  interest,  since  their  growth  may  exert 
such  marked  compression  upon  the  sac  that  its  opposed 
inner  surfaces  finally  become  completely  adherent  and  thus 
obliterate  its  cavity.  In  this  manner  it  is  possible  that  a 
hernia  might  undergo  a  spontaneous  cure.  If  the  growing 
lipoma,  instead  of  exerting  a  uniform  pressure  upon  the 
entire  sac,  simply  compresses  a  portion  of  it,  the  adhesion 
of  the  serous  surfaces  takes  place  in  this  situation  only, 
and  a  part  of  the  hernial  sac  may  be  cut  off  as  a  com- 
pletely closed  cyst.  Such  cysts  upon  hernial  sacs  may 
also  be  formed  in  other  ways  (see  Figs.  51  and  52),  and 
their  presence  makes  the  recognition  of  the  hernial  con- 
tents much  more  difficult. 


THE  ORIGIN  OF  ABDOMINAL  HERNIAS* 

The  mechanism  of  the  formation  of  hernia  is  of  con- 
siderable and  by  no  means  purely  theoretic  interest.  If 
the  causes  of  an  ailment  are  known,  its  permanent  cure 
may  be  more  readily  accomplished,  and  Avith  the  present 
rapid  growth  of  the  accident  insurance  laws,  the  physician 
is  called  upon  so  frequently  to  express  an  opinion  upon 
the  etiologic  connection  between  an  accident  and  an  abdo- 
minal hernia  that  he  has  a  pressing  and  undeniable  need 
of  an  exact  knowledge  of  the  mechanism  involved. 

The  previously  mentioned  supposition  that  a  hernia  was 
preceded  by  a  rupture  of  the  peritoneum  was  particularly 
held  in  reference  to  strangulated  hernia,  while  non-strangu- 


ORIGIN  OF  ABD03IINAL  HERNIAS.  51 

lated  hernias  were  supposed  to  result  from  a  relaxation  and 
displacement  of  this  membrane.  These  were  the  funda- 
mental views  which  were  generally  accepted  from  the  most 
ancient  times  until  the  beginning  of  the  eighteenth  century, 
and  it  was  not  until  this  time,  most  important  for  the 
development  of  surgery  in  general,  that  Mery  (1701)  pub- 
lished some  observations  intended  to  prove  that  the  peri- 
toneum was  not  torn,  but  simply  stretched,  in  the  forma- 
tion of  a  hernia.  Corvillard  (1672)  had  previously  dis- 
covered that  there  were  certain  congenital  hernias  which 
were  completely  formed  before  birth.  Reneaulme  de 
Lagaranne  and  Garengeot  (about  1730)  gave  the  first 
complete  description,  in  a  more  scientific  manner,  of  the 
mechanism  of  the  formation  of  a  hernia.  They  supposed 
that  the  intestines  were  subjected  to  pressure  upon  all  sides 
by  the  abdominal  muscles  and  diaphragm,  from  which  they 
attempted  to  escape  through  the  weak  portions  of  the 
abdominal  wall,  particularly  in  thpse  places  which  give 
exit  to  the  vessels.  In  these  situations  they  believed  that 
the  peritoneum  was  pushed  outward,  either  gradually  or 
suddenly,  by  the  abdominal  pressure  and  the  weight  of  the 
intestine,  which  they  supposed  to  be  filled  with  solid  feces. 
No  further  mention  of  a  rupture  of  the  peritoneum  is  made 
by  Garengeot.  A  marked  advance  in  the  understanding 
of  the  development  of  hernia  is  seen  in  the  theory  of  Bene- 
voli  (1797),  that  the  causes  previously  given  for  the  forma- 
tion of  a  hernia  were  not  sufficient,  but  that  an  additional 
factor  was  necessary — namely,  a  relaxation  of  the  mesen- 
tery. Whether  this  relaxation  is  primary  or  whether  the 
mesentery  elongates  secondarily  from  the  descent  of  the 
intestine  into  the  hernia,  long  remained  a  subject  of  con- 
troversy, and  has  not  been  definitely  decided  even  at  the 
present  day.  Cloquet  (1819)  treated  the  subject  from 
another  standpoint,  and  was  the  first  to  suggest  that  hernia 
could  arise  not  only  from  pressure  from  within,  but  also 
from  traction  from  without.  The  testicle,  for  example, 
in  its  descent  could  draw  the  intestine  after  it,  or  a  sub- 
peritoneal lipoma  could,  by  means  of  its  pedicle,  make 
traction  upon  the  peritoneum  and  thus  form  a  hernial  sac. 
Roser  (1843),  followed  by  Linhart  (1865),  elaborated  the 


52  HERNIA. 

latter  theory,  and  claimed  that,  in  femoral  hernia  at  least, 
the  traction  of  such  a  subperitoneal  lipoma  was  to  be  con- 
sidered as  the  usual  cause  of  the  development  of  the  hernia. 

Recently  Koch  (Dorpat)  and  his  followers  have  ad- 
vanced the  theory  that  neither  traction  from  without  nor 
pressure  from  within  can  produce  a  hernial  sac  during 
extra-uterine  life,  but  that,  with  the  rare  exception  of  those 
formed  by  cicatricial  tissue,  all  hernial  sacs  are  congenital. 
They  assume  not  only  that  the  hernial  sac  is  congenital, 
but  also  that  the  intestinal  coil  within  the  sac  has  attained 
this  position  from  some  congenital  peculiarity  of  its  situa- 
tion or  attachment  within  the  abdomen.  Koch  recognizes 
the  possibility  of  the  enlargement  of  a  congenital  hernia 
in  later  life,  and  explains  such  an  occurrence  by  the  mobility 
of  the  peritoneum,  and  probably  also  by  a  specific  theory 
of  growth. 

At  the  first  glance  Koch's  theory  is  apparently  favored 
by  the  influence  of  heredity  upon  the  occurrence  of  hernia, 
which  is  shown  in  Berger's  statistics,  inasmuch  as  members 
of  the  same  family  are  frequently  affected.  This,  however, 
proves  nothing,  since  the  conditions  which  favor  the  de- 
velopment of  hernia,  such  as  the  degree  of  resistance  of 
the  abdominal  wall  and  the  size  of  the  hernial  orifice,  are 
also  inherited  and  could  influence  the  development  of  the 
hernia  in  the  parent  as  well  as  in  the  child.  The  univers- 
ally recognized  rarity  of  femoral  hernia  in  childhood  speaks 
against  Koch's  theory.  The  statistics  of  Berger  show  but 
9  femoral  hernias  in  1518  cases  of  hernia  in  children  under 
fifteen  years  of  age.  [I  have  recently  analyzed  9882  cases 
of  hernia  in  children  under  fourteen  years  of  age  treated 
at  the  Hospital  for  Ruptured  and  Crippled  in  New  York, 
and  found  60  cases  of  femoral,  or  the  proportion  of  1 :  164 
inguinal. — Ed.]  Even  if  the  hernial  sac  were  congenital, 
and  the  femoral  hernia  became  completely  developed  later 
in  life  by  the  descent  of  the  hernial  contents,  autopsies 
upon  the  newborn  should  have  revealed  the  presence  of  a 
peritoneal  diverticulum  much  oftener  than  has  been  the 
case.  As  long  as  such  a  congenital  predisposition  is  not 
supported  by  anatomic  evidence,  it  will  be  well  to  regard 
Koch's  theory  with  a  great  deal  of  skepticism. 


ORIGIN  OF  ABDOMINAL  HERNIAS.  53 

The  prevalent  views  in  reference  to  the  origin  of  abdom- 
inal hernia  may  be  ex])ressed  as  follows  : 

1.  Congenital  hernias  are  observed  which  are  complete 
at  birth,  even  the  hernial  contents  being  present.  They 
are  to  be  regarded  as  disturbances  of  development,  and 
such  disturbances  of  development  occur  almost  exclusively 
in  umbilical,  inguinal,  and  diaphragmatic  hernia.  There 
are  other  cases  in  which  only  the  hernial  sac  is  congenital, 
and  this  is  observed  particularly  in  external  inguinal 
hernia.  In  such  individuals  there  is  no  sign  of  the  pres- 
ence of  a  hernial  sac,  and  it  probably  is  not  until  there  is 
a  sudden  violent  augmentation  of  the  intra-abdominal 
tension  by  sneezing,  crying,  a  fall,  a  blow  upon  the  abdo- 
men, or  by  lifting  heavy  weights,  that  the  intestine  is 
forced  into  the  sac  and  the  hernia  is  complete  in  all  its 
parts.  In  these  cases  there  is  a  congenital  predisposition 
to  hernia,  since  the  sac  exists  at  birth,  but  the  hernia  is 
not  completed  until  one  of  the  just  mentioned  exciting 
causes  is  brought  into  play.  In  a  similar  manner  the 
intestine  may  be  forced  into  a  congenital  sac  by  a  fre- 
quently repeated  moderate  increase  of  the  intra-abdominal 
tension,  and  thus  complete  the  formation  of  a  hernia. 

2.  In  addition  to  congenital,  we  have  acquired  hernias. 
They  are  characterized  by  the  fact  that  they  never  arise 
from  a  single  increase  in  the  intra-abdominal  pressure,  be 
it  ever  so  violent,  but  make  their  appearance  gradually. 
As  Graser  very  correctly  emphasizes,  the  development  of 
the  majority  of  acquired  hernias  is  not  due  to  any  one 
cause,  but  to  a  series  of  diiferent  influences.  As  far  as 
the  development  of  the  hernial  sac  is  concerned,  the  yield- 
ing of  the  peritoneum  is  due  to  the  fact  that  the  abdom- 


64  HERNIA. 

inal  wall  is  less  capable  of  resistance  in  certain  situa- 
tions, and  that  the  peritoneum,  which  is  easily  movable 
upon  its  bed  of  loose  areolar  tissue,  attempts  to  escape 
from  the  repeated  augmentations  of  the  intra-abdominal 
tension  through  the  places  of  decreased  resistance.  The 
majority  of  hernialogists  agree  that  the  development  of 
the  hernial  sac  is  favored  both  by  rapid  emaciation  and  by 
the  rapid  accumulation  of  fat.  Paradoxical  as  this  may 
sound,  the  explanation  given  is  nevertheless  a  plausible 
one.  With  the  occurrence  of  general  emaciation,  the 
fatty  tissue  filling  up  the  hernial  orifices  usually  disap- 
pears, and  these  places,  which  were  already  less  resistant, 
become  more  yielding  and  relaxed  ;  with  the  rapid  appear- 
ance of  obesity  there  is  an  increase  in  the  amount  of  the 
subperitoneal  areolar  tissue,  and  this  consequently  results 
in  a  greater  mobility  of  the  peritoneum.  The  traction  of 
a  rapidly  growing  subperitoneal  lipoma  upon  the  peri- 
toneum, to  which  it  is  tightly  adherent,  is  also  a  factor  in 
the  development  of  a  hernial  sac,  although  it  does  not 
follow  that  this  method  of  origin  is  frequent,  or,  as  Roser 
claimed,  the  usual  one. 

3.  The  enlargement  of  a  pre-existing  hernial  sac  is  due 
in  a  slight  measure  to  elastic  extension,  but  chiefly  to  a 
greater  or  less  degree  of  mobility  of  the  peritoneum  upon 
the  underlying  structures.  In  my  opinion,  however,  the 
ability  of  the  sac  to  enlarge  from  an  increased  growth  of 
its  peritoneal  surface  is  worthy  of  particular  attention.  If 
a  cyst  which  is  lined  with  epithelium  becomes  very  tensely 
filled,  the  pressure  of  the  secreted  fluid  acts  as  a  stimulant, 
and  the  walls  enlarge  more  by  actual  growth  than  by  a 
flattening  and  stretching  of  the  cellular   elements.     We 


ORIGIN  OF  ABDOMINAL  HERNIAS.  55 

must  also  assume  that  a  similar  eifect  is  produced  upou  the 
inner  surface  of  a  hernial  sac  which  is  constantly  irritated 
by  the  repeated  forcing  of  the  intestine  against  its  wall. 

4.  Only  those  portions  of  the  intestines  may  enter  into 
a  hernial  sac  which  are  enabled  to  do  so  by  their  position, 
and  particularly  by  the  length  of  their  mesenteries.  AVe 
must  consequently  assume  that  a  congenital  predisposition 
enables  the  intestine  to  pass  the  hernial  orifice,  but  that 
with  the  enlargement  of  the  hernia  it  is  possible  for  the 
mesentery  to  elongate  by  a  process  of  growth  similar  to 
that  described  in  reference  to  the  hernial  sac. 

5.  Both  the  origin  and  the  enlargement  of  a  hernia  are 
favored  by  certain  pathologic  conditions,  particularly  those 
of  the  respiratory  apparatus,  by  pregnancy,  and  by  certain 
occupations. 

The  pathologic  conditions  of  the  respiratory  organs 
which  favor  the  development  of  hernia  are  acute  and 
chronic  bronchitis ;  whooping-cough ;  and  probably  also 
nasal  obstruction — from  adenoid  proliferations,  for  exam- 
ple, on  account  of  the  associated  exertion  in  breathing. 
Other  factors  to  be  considered  are  gastro-intestinal  diseases, 
particularly  chronic  constipation,  and  anything  which  hin- 
ders the  emptying  of  the  bladder  (phimosis).  The  stretch- 
ing and  subsequent  relaxation  of  the  abdominal  wall  in 
pregnancy  is  a  sufficient  explanation  for  the  frequency  of 
hernia  in  multipara.  According  to  Berger,  those  occupa- 
tions which  require  the  output  of  considerable  muscular 
effort  combined  with  increased  demands  upon  the  thoracic 
organs  are  the  ones  which  most  strongly  predispose  to 
hernia. 

In  the  critical  examination  of  a  causal  relation  between 


56  HERNIA. 

hernia  and  accident  we  must  remember,  first  of  all,  that  a 
hernia,  complete  in  all  its  parts,  can  never  arise  at  the 
moment  of  an  accident,  or  by  a  single  augmentation  of  the 
intra-abdominal  tension,  be  it  ever  so  great.  If  the  hernia 
first  appears  at  the  time  of  the  accident,  we  may  certainly 
suppose  that  the  hernial  sac  was  either  congenital  or  grad- 
ually formed  in  the  manner  already  described.  [Bil- 
finger's  ^  recent  paper  on  "Traumatic  Hernia"  proves  that 
traumatic  hernia,  though  rare,  docs  occur,  and  cites  a  case. 
I  have  recently  observed  an  undoubted  case  myself.  It 
was  of  the  direct  variety  and  there  was  no  pre-existing  sac. 
The  hernia  appeared  immediately  after  the  injury. — Ed.] 
After  a  severe  subcutaneous  wound  of  the  abdominal  wall 
in  which  the  parietal  peritoneum  has  also  been  torn,  it  is 
possible  that  the  abdominal  scar  may  stretch  and  lead  to 
a  hernial  protrusion  when  the  patient  leaves  his  bed  and 
resumes  his  ordinary  occupation.  These  cases,  which  are 
to  be  classified  with  the  hernia  of  scars  (page  31),  are, 
however,  very  rare.  Such  wounds  may  occasionally  be 
recognized  by  the  immediate  consequences  of  the  lesion — 
swelling,  pain,  tenderness,  and  the  effusion  of  blood,  but 
these  symptoms  may  also  be  absent. 

Although  it  must  be  unconditionally  accepted  that  a 
hernia  making  its  appearance  at  the  time  of  the  injury  has 
never  completely  developed  at  that  moment,  a  causal  con- 
nection must  nevertheless  be  recognized,  since  a  pre-existing 
condition  has  been  made  worse  by  the  accident  ^  or  injury. 

1  Archiv  f.  klin.  Chir.,  Bd.  lxiv,  No.  1,  901. 

2  By  an  accident  is  meant  that  the  affected  individual  suffers  an 
impairment  of  his  physical  or  mental  condition,  or  even  death,  whether 
it  be  from  external  injury  or  from  organic  disease,  and  that  this  impair- 


ORIGIN  OF  ABDOMINAL  HERNIAS.  bl 

The  investigation  as  to  wlicther  a  hernia  has  previously 
existed  is  consequently  very  essential  for  a  critical  judg- 
ment upon  this  question.  The  following  are  some  of  the 
questions  which  nuist  he  asked  :  Has  the  injured  indi- 
vidual ever  been  examined  by  a  physician  for  any  other 
disease?  Has  he  been  a  soldier?  Did  he  tell  his  fellow- 
workmen  immediately  of  the  hernial  tumor  Avhich  he  claims 
suddenly  appeared  ?  How  nuich  time  elapsed  after  the 
injury  before  he  consulted  a  physician,  and  what  did  the 
physician  observe?  Are  traces  of  the  injury  still  present 
and  can  a  conclusion  be  drawn  from  the  size  of  the  hernia 
and  from  the  thickness  of  its  coverings  that  it  must  have 
existed  for  a  considerable  time  ? 

The  further  questions  as  to  whether  the  injury  is  to  be 
regarded  as  an  accident,  and  whether  it  can  be  proved  by 
witnesses  that  a  hernia  did  not  previously  exist,  are  sub- 
jects for  judicial  decision,  and  frequently  have  nothing  to 
do  with  the  medical  opinion. 

It  has  recently  been  stated  by  Russian  physicians  that 
inguinal  hernia  may  also  be  artificially  produced,  and  that 
such  attempts  have  been  made  in  order  to  escape  military 
service.  More  exact  information  upon  this  point  Avill  be 
found  in  the  section  upon  expert  opinions  in  reference  to 
hernia. 

ment  can  be  traced  to  a  certain  event  which  has  suddenly  occurred — 
/.  e.,  within  a  definite  and  relatively  short  period  of  time.  It  is  also 
possible  that  the  results  of  this  injury  may  gradually  make  their  ap- 
pearance. Another  idea  involved  in  the  conception  of  an  accident  is 
that  the  amount  of  exertion  ordinarily  associated  with  the  particular 
occupation  of  the  individual  must  be  exceeded,  or  that  the  exertion 
must  be  out  of  the  ordinary  as  a  result  of  something  unusual  in  con- 
nection with  the  occupation. 


58  HERNIA. 

THE  GENERAL  DIAGNOSIS  OF  HERNIA. 

The  diagnosis  of  hernia  is  greatly  aided  by  a  careful 
study  of  the  anamnesis,  which  will  show  whether  the 
swelling  in  question  developed  suddenly  or  gradually, 
whether  it  seemed  to  originate  from  within  the  abdomen, 
whether  it  has  a-lways  been  of  the  same  size,  or  whether 
the  protrusion  is  smaller  or  absent  when  the  patient  rises 
in  the  morning.  It  is  also  of  interest  to  ascertain  whether 
the  patient  has  become  rapidly  emaciated  or,  on  the  con- 
trary, rapidly  obese  ;  what  occupation  he  follows  ;  and,  in 
the  case  of  women,  whether  they  have  borne  children,  and, 
if  so,  how  many.  The  patients  ordinarily  state  that  they 
have  pain  which  is  either  localized  at  the  hernial  orifice  or 
reflected  from  there  to  the  abdomen  ;  that  they  suifer  from 
digestive  disturbances,  such  as  nausea  and  occasional  vomit- 
ing ;  and  that  they  are  troubled  with  constipation.  These 
latter  symptoms  demand  considerable  attention  in  the  very 
beginning  of  the  affection,  when  there  is  as  yet  no  distinct 
external  protrusion.  [My  own  experience  is  that  the 
symptoms  are  seldom  of  sufficient  importance  to  attract 
the  attention  of  the  patient  prior  to  the  appearance  of  the 
swelling. — Ed.] 

The  examination  commences  with  inspection,  which 
reveals  whether  the  position  of  the  swelling  corresponds  to 
one  of  the  hernial  orifices ;  whether  it  is  sharply  outlined 
or  seems  to  have  a  pedicle  connecting  it  with  the  interior 
of  the  abdomen ;  whether  the  size  of  the  tumor  changes 
when  the  patient  alternately  assumes  the  erect  and  the 
horizontal  positions  ;  and  particularly  whether  there  is  an 
enlargement  and  increased  tension  of  the  protruded  parts, 


GENERAL  DIAGNOSIS.  59 

with  augmentations  of  the  intra-abdominal  pressure,  such 
as  that  produced  by  coughing,  for  example.  In  sparely 
built  individuals  it  is  sometimes  possible  to  recognize 
through  the  skin  the  contours  of  the  intestinal  coils  situ- 
ated within  the  sac. 

Additional  conclusions  may  be  drawn  from  palpation. 
If  an  external  swelling  is  visible,  it  is  to  be  grasped 
between  the  thumb  and  index-finger  and  an  attempt  made 
to  differentiate  its  base  from  the  abdomen.  If  the  case  is 
one  of  hernia,  such  a  differentiation  is  impossible,  and  a 
more  or  less  thick  cord  is  felt  between  the  finoers.  One 
of  the  surest  signs  of  hernia  is  obtained  when  it  is  possi- 
ble to  replace  the  protruded  parts  into  the  abdominal  cavity 
by  external  pressure.  In  large  hernias  this  is  not  easy, 
and  in  such  cases  it  is  well  to  leave  the  reposition  to  the 
patient  himself,  who  usually  has  acquired  a  certain  skill  in 
this  procedure.  As  soon  as  the  tumor  has  been  forced 
back,  the  skin  of  the  scrotum  should  be  invaglnated  and 
the  index-finger  carried  into  the  hernial  orifice  in  order  to 
obtain  an  idea  of  its  size  (Fig.  17).  A  rough  measure 
may  be  made  by  observing  how  many  fingers  may  be  com- 
fortably passed  through  the  hernial  orifice.  If  the  skin  is 
not  invaginated  and  an  attempt  is  made  to  force  the  finger 
directly  into  the  mouth  of  the  hernia,  the  skin  becomes  so 
tense  that  it  hinders  the  advance  of  the  finger. 

If  this  method  is  followed  in  the  examination  of  the 
hernial  orifice  of  a  patient  who  has  as  yet  developed  no 
distinct  external  protrusion,  a  distinct  impulse  upon  cough- 
ing is  felt,  the  intestines  striking  upon  the  palpating 
finger.  Such  an  impulse  alone  is,  nevertheless,  no  proof 
of  the  presence  of  a  commencing  hernia,  and  it  is  only 


60 


HERNIA. 


Fig.  17.— The  position  of   the  liand  and  the  invagination  of  the 
skin  in  the  examination  of  the  mouth  of  an  inguinal  hernia. 


GENERAL  DIAGNOSIS.  Gl 

after  repeated  examinations  Avhicli  show  an  inereane  of  the 
impulse  or  tlie  development  of  a  hernia  at  the  correspond- 
ing point  upon  the  opposite  side  that  there  is  any  justi- 
fication for  such  a  diagnosis. 

If  the  hernia  contains  intestinCj  reduction  is  accom- 
panied by  a  very  characteristic  gurgle,  and  it  not  rarely 
happens  that  pressure  will  cause  the  entire  contents  to 
suddenly  slip  back  into  the  abdominal  cavity.  If  loops 
of  intestine  are  present,  the  percussion  note  over  the  swell- 
ing is  frequently  tympanitic,  although  this  sign  may  easily 
be  wanting  if  the  intestinal  loop  is  small,  if  it  is  covered 
by  omentum,  or  if  much  hernial  fluid  is  present.  While 
an  intestinal  hernia  is  uniformly  smooth  and  elastic  to  the 
touch,  an  omental  hernia  is  usually  harder,  feels  rather 
lumpy,  and  its  reduction  is  never  so  rapidly  accomplished. 

If  the  hernia  is  irreducible,  the  diagnosis  is  more  diffi- 
cult. The  causes  of  the  irreducibility  are  mostly  to  be 
found  in  adhesions  in  the  contents  themselves  or  between 
the  contents  and  the  hernial  sac.  In  omental  hernia,  such 
adhesions  to  the  sac  are  quite  common,  and  it  frequently 
happens  that  the  contiguous  omental  surfaces  become  adher- 
ent, or  sometimes  even  calcified,  into  a  thick  lump,  and 
thus  are  unable  to  pass  back  through  the  narrow  hernial 
orifice.  [Calcification  is  of  extreme  rarity. — Ed.]  In 
other  cases,  intestinal  loops  which  have  been  in  a  hernial 
sac  for  a  considerable  time  may  become  mutually  adherent 
from  some  inflammatory  or  mechanical  irritation, — such  as 
the  pressure  of  a  badly  fitting  truss,  for  example, — and 
form  such  a  thickened  mass  of  convolutions  that  their 
reposition  is  impossible.  A  hernia  must  also  be  irreduci- 
ble if  its  contents  are  formed  by  some  viscus  which  is  only 


62  HERNIA. 

partially  covered  by  peritoneum  (ascending  colon,  descend- 
ing colon,  cecum,  urinary  bladder),  since  these  organs  are 
naturally  tightly  adherent  to  the  peritoneum  and  can  only 
change  their  positions  in  association  with  this  membrane. 
The  reposition  of  the  sac  of  the  hernia  is,  however,  almost 
always  impossible.  After  a  consideration  of  all  the  symp- 
toms, which  in  reference  to  pain  and  digestive  disturbances 
are  apt  to  be  much  more  pronounced  in  irreducible  her- 
nia, it  will  usually  be  possible  to  make  the  diagnosis. 

Since  hernias  are  most  likely  to  be  confused  with  cysts, 
swollen  lymphatic  glands,  and  lipomata,  more  rarely  w^ith 
other  new-growths,  these  affections  consequently  require 
particular  attention  from  a  differential  diagnostic  stand- 
point. The  differentiation  of  a  hernia,  and  particularly  of 
an  omental  hernia,  from  a  subperitoneal  lipoma  is  by  no 
means  easy,  and  sometimes  absolutely  impossible.  As  we 
have  already  seen,  the  position  of  a  lipoma,  the  form  and 
consistence,  the  impulse  on  coughing,  and  the  possibility 
of  partial  reduction  may  be  similar  to  that  of  an  omental 
hernia,  and  since  the  symptoms  of  the  patient  with  a 
lipoma  may  be  like  those  of  a  patient  with  a  rupture,  the 
reason  for  the  difficulty  of  differentiation  in  such  cases  is 
understood.  The  cases  which  present  such  diagnostic  dif- 
ficulties are  nevertheless  in  the  minority,  and  the  subper- 
itoneal lipoma  will  usually  be  recognized  as  such  by  its 
situation  in  certain  predisposed  locations,  such  as  the  linea 
alba,  femoral,  or  umbilical  region,  and  since  it  maintains 
the  same  degree  of  tension,  although  often  more  markedly 
protruded  by  augmentations  of  the  intra-abdominal  pres- 
sure. Subperitoneal  lipomata  of  the  inguinal  region  are 
very  rare. 


GENERAL  TREATMENT.  63 

Cysts  and  solid  tumors  may  be  differentiated  from  a 
hernia  by  the  fact  that  they  may  be  lifted  up  from  the 
abdominal  wall  and  sharply  isolated  from  it,  since  they 
have  no  pedicle.  In  addition  to  this,  cysts  with  clear  con- 
tents are  transparent.  Variations  in  the  intra-abdominal 
tension  have  no  effect  upon  either  the  volume  or  the  ten- 
sion of  solid  or  cystic  tumors. 

The  differential  diagnostic  factors  which  are  of  impor- 
tance in  reference  to  individual  hernias  will  be  particu- 
larly pointed  out  in  the  section  upon  '^  Special  Hernias." 


GENERAL  TREATMENT. 

Before  we  consider  the  remedies  which  we  possess  for 
the  improvement  and  cure  of  abdominal  hernia  it  should 
be  stated  that  a  hernia  may  undergo  a  spontaneous  cure. 
We  have  already  learned  how  the  growth  of  a  subperi- 
toneal lipoma  may  cause  the  obliteration  of  a  hernial  sac-. 
It  more  frequently  happens,  particularly  in  young  chil- 
dren, that  the  w^alls  of  the  narrow  neck  of  the  sac  become 
directly  apposed,  and  finally  adhere  to  each  other;  the 
remaining  portion  of  the  hernial  sac  may  become  obliter- 
ated in  the  same  manner  or  it  may  remain  as  a  closed 
serous  sac  which  at  any  time  may  give  rise  to  the  forma- 
tion of  a  cyst  by  the  secretion  of  fluid.  In  no  small 
number  of  cases  a  spontaneous  cure  is  only  simulated. 
This  is  chiefly  observed  in  those  cases  in  which  a  hernia 
present  in  youth  has  disappeared  with  advancing  years. 
There  has  been  no  obliteration  of  the  hernial  sac  or  of  its 
neck,  but  although  the  sac  remains  unchanged,  the  mouth 
of  the  hernia  has  become  so  markedly  narrowed  by  the 


64  HERNIA. 

growth  of  the  body  that  it  hinders  the  ))assage  of  a  viscus. 
In  later  life  the  hernia  may  reappear  in  such  individuals 
if  the  abdominal  walls  are  relaxed  and  the  intra-abdominal 
tension  greatly  increased. 

The  treatment  of  an  ordinary  reducible  hernia  may  be 
either  palliative  or  radical.  The  palliative  treatment  is 
the  treatment  by  means  of  a  truss,  and  has  in  view  the 
reposition  of  the  hernial  tumor  and  the  maintenance  of 
this  reposition  by  an  appropriate  support.  If  properly 
applied,  it  may  cause  a  disappearance  of  the  symptoms, 
prevent  the  further  enlargement  of  the  protrusion,  and 
aid  in  the  spontaneous  cure  of  hernias  in  the  early  years 
of  life. 

The  radical  treatment  aims  at  the  complete  and  per- 
manent cure  of  the  hernia,  and  is  an  operative  one. 

The  Palliative  Treatment. — The  fundamental  requis- 
ite for  the  application  of  a  truss  is  that  the  hernia  is 
reducible.  If  the  truss  is  applied  while  portions  of  the 
viscera  are  still  within  the  sac,  the  attempt  to  close  the 
hernial  orifice  will  not  only  be  fruitless,  but  the  continuous 
pressure  injures  the  protruded  viscera  and  produces  pain, 
since  the  irritation  causes  the  formation  of  adhesions  ;  tlie 
affection  is  made  worse  and  a  freely  movable  hernia  is 
converted  into  an  irreducible  one.  Before  the  application 
of  a  truss  our  first  duty  is  consequently  to  reduce  the 
hernia,  and  this  procedure  is  known  as  taxis.  The  per- 
formance of  taxis  is  usually  quite  simple  in  small  hernias, 
the  tumor  being  grasped  by  the  hand  and  squeezed  like  a 
sponge.  In  larger  hernias,  taxis  may  be  quite  difficult  and 
require  the  aid  of  several  adjuvants.  In  the  first  place, 
the   muscles  of   the   abdominal  wall   should  be   relaxed 


GENERAL  TREATMENT.  65 

This  may  be  accomplished  by  having  the  patient  hc^hl  his 
montli  wide  open  and  breathe  deeply,  and  by  placing  a 
cushion  beneath  the  pelvis,  the  lower  extremities  being 
flexed  at  the  hips  and  knees.  If  the  patient  is  kept  in 
this  position  through  the  night,  the  liernia  will  frequently 
become  spontaneously  reduced  without  the  aid  of  any 
manipulation  whatever.  Taxis  is  also  more  readily  per- 
formed if  the  intestinal  coils  within  the  hernial  sac  are  not 
filled  with  feces,  and  the  cautious  administration  of  purga- 
tives by  the  mouth  and  of  large  enemata  are  consequently 
of  service.  Very  large  hernias  which  are  difficult  of  re- 
duction may  sometimes  be  replaced  if  an  elastic  bandage  is 
evenly  applied  about  the  entire  hernial  protrusion  and  allowed 
to  exert  a  uniform  pressure  for  several  hours.  After  a 
successful  taxis  the  application  of  a  truss  is  indicated.  If 
taxis  is  impossible  and  if  operation  is  contraindicated  or 
refused  by  the  patient,  we  must  content  ourselves  with  the 
application  of  a  truss  with  a  cup-shaped  pad  or  of  some 
form  of  suspensory. 

The  knowledge  of  the  application  of  the  truss  (6ra- 
cherium)  dates  back  to  the  time  of  CelsuS;  who  employed 
a  soft  strap  provided  with  a  plate,  and  in  this  manner 
frequently  succeeded  in  curing  hernia  in  boys.  For  a 
long  time  plates  were  employed,  which  were  fastened  over 
the  hernial  orifice  by  a  strongly  adherent  plaster  (Lan- 
franchi,  about  1300).  Gordon  (1305)  seems  to  have  been 
the  first  to  mention  a  spring  truss,  but  this  suggestion  was 
very  soon  forgotten,  and  it  was  not  until  1785  that  the 
truss,  practically  as  it  is  still  in  use  at  the  present  day, 
was  rediscovered  and  introduced  by  the  Dutch  physician, 
Peter  Camper. 

The  truss  consists  of  a  steel  spring  the  anterior  extrem- 
ity of  w^hich  is  provided  with  a  pear-shaped  pad.     Conical 


66 


HERNIA. 


Fig.  18. 


pads  which  project  into  the  hernial  orifice  and  are  snp- 
posed  to  block  it  up  simply  dilate  the  mouth  of  the  hernia, 
and  should  therefore  be  unreservedly  condemned.  Figure 
18  shows  the  rough  spring  which  at  its  anterior  extremity 

is  continuous  with  a  metal 
plate  provided  with  two 
pins  or  buttons.  This 
plate  is  loosely  covered 
with  a  case  of  stout 
drilling  which  is  firmly 
stuffed,  on  the  side  next 
the  body,  with  horsehair,  cotton,  wood-fiber,  sea-grass,  or, 
best  of  all,  with  the  so-called  '•'■  pig's- wool ''  (the  soft  hair 
which  is  shed  by  the  pig).  A  thin  leather  covering  is 
stitched  over  the  pad  and  spring  and  continued  beyond 
the  end  of  the  spring  as  a  strap  which  embraces  the  oppo- 
site half  of  the  body  and  is  fastened  to  one  of  the  buttons 
upon  the  pad  (Fig.  19). 
In  certain  cases  the  posi- 
tion and  size  of  the  her- 
nia make  it  necessary  to 
add  a  perineal  strap, 
which  gives  the  pad 
additional  fixation  (see 
Figs.  54  and  79).  In 
this  truss  the  spring  en- 
circles the  affected  side,  while  the  complementary  strap, 
which  represents  the  continuation  of  the  spring,  embraces 
the  other  half  of  the  body.  The  strength  of  the  spring  to 
be  employed  is  dependent  upon  the  size  of  the  hernial  ori- 
fice, upon  the  age  of  the  patient,  and  also  upon  the  amount 


Fig.  19. — French  truss. 


GENERAL  TREATMENT. 


67 


of  force  with  which  the  hernia  is  ])rotnulc(l.  The  truss 
should  not  change  its  position  in  walking,  lying,  or  sitting, 
and  is  ordinarily  worn  only  during  the  day.  If  the  patient 
coughs  frequently,  or  if  there  is  a  possibility  of  cure  by 
means  of  the  truss,  it  should  be  worn  both  day  and  night. 
If  the  hernia  is  bilateral,  a  double  truss  is  to  be  applied,  and 
this  is  best  made  by  placing  the  free  ends  of  two  springs 
together  and  holding  them  in  this  position  by  means  of  a 
buckle  attached  to  their  leather  coverings.  In  such  a  truss 
the  distance  between  the  two  pads 
may  be  regulated  at  pleasure. 
The  most  important  part  is  the 
spring,  upon  the  curve  and 
strength  of  which  the  worth  and 
applicability  of  the  truss  are  al- 
most entirely  dependent.  The 
many  modifications  of  the  truss 
almost  exclusively  affect  the  na- 
ture of  the  pad,  and  of  these 
modifications  I  will  mention  only 
the   spring-pad,  the  hard-rubber 

pad,  and  the  pad  made  by  filling  a  small  rubber  bag  with 
fluid  (glycerin). 

The  so-called  English  or  Salmon's  truss  (Fig.  20)  is 
somewhat  differently  constructed  from  that  of  Camper. 
Freely  movable  pads  are  attached  to  both  ends  of  the 
spring  by  ball-and-socket  joints ;  the  anterior  pad  closes 
the  hernial  orifice,  the  posterior  pad  rests  upon  the 
sacral  region,  and  the  spring  encircles  the  normal  half  of 
the  body  without  touchino-  the  skin.  In  this  truss  the 
complementary  and  perineal  straps  are  unnecessary.     Al- 


Fig.  20. — Cross-body 
truss. 


68  HERNIA. 

though  very  popular  in  England  and  America,  this  truss 
has  nevertheless  been  but  little  employed  in  Germany. 

The  general  rules  for  the  treatment  by  means  of  a  truss 
are  as  follows  : 

1.  The  hernia  must  be  reduced  before  the  application 
of  the  truss. 

2.  The  pad  must  always  be  placed  in  direct  contact  with 
the  skin  or  upon  a  small  piece  of  linen. 

3.  The  pressure  of  the  pad  must  never  be  so  great  as 
to  injure  the  skin ;  cutaneous  excoriation  may  frequently 
be  prevented  by  scrupulous  cleanliness  of  the  hernial 
region  and  by  repeated  bathing  with  alcohol. 

4.  When  the  truss  has  been  applied,  be  sure  that  it 
retains  the  hernia  when  the  patient  walks,  sits,  lies 
down,  goes  upstairs,  bends  backward  and  forward,  and 
coughs. 

5.  In  children  the  chances  of  recovery  are  more  favor- 
able the  earlier  the  treatment  with  the  truss  is  commenced. 
A  truss  may  ordinarily  be  applied  when  the  child  is  three 
or  four  months  old.  In  these  cases  a  washable  pad  of  hard 
rubber  is  to  be  recommended. 

Certain  details  which  are  of  importance  in  the  diiferent 
varieties  of  the  truss  will  receive  particular  attention  in  the 
section  upon  '^  Special  Hernias.''  [After  the  age  of  pub- 
erty cure  by  truss  treatment  is  very  rare  in  inguinal  her- 
nia, and  femoral  hernia  at  any  age  is  practically  incurable 
by  mechanical  treatment. — Ed.] 

The  Radical  Operation. — Since  the  earliest  times 
efforts  have  been  made  to  cure  hernia  by  operation,  and 
these  efforts  have  constantly  been  renewed  on  account  of 
the  unreliability  of  the  older  methods  of  retention.     Good 


GENERAL  TREATMENT.  69 

results  were  not  obtained  until  the  beginning  of  the  anti- 
septic era,  and,  at  tlie  ])resent  day,  tlie  procedures  formerly 
adopted  have  only  a  historic  interest.  For  centuries  the 
radical  operation  was  practised  only  by  strolling  laymen, 
who  Avere  known  as  'Miernia  cutters"  (^Bruchschnelder). 
The  results  were  poor,  and  in  the  most  frequent  variety, 
the  inguinal  hernia,  the  ligation  of  the  sac  was  always 
accompanied  by  castration.  On  account  of  these  reasons 
the  operation  fell  into  disrepute,  the  craft  was  considered 
dishonorable,  and  in  the  eighteenth  century,  when  reputa- 
ble surgeons  commenced  to  operate  for  hernia,  the  "  hernia 
cutters  "  completely  disappeared. 

The  following  table  is  a  brief  review  of  the  methods 
employed  for  the  radical  cure  before  the  beginning  of  the 
antiseptic  era  : 

1.  The  obliteration  of  the  hernial  orifice  by  the  actual 
cautery,  according  to  the  method  of  Abulkasim,  who  re- 
placed the  hernia  and  burned  the  hernial  region  to  the  bone. 

2.  Attempts  to  obliterate  the  hernial  orifice  or  the  sac 
itself  by  the  production  of  scar  tissue. 

Velpeau:  Injection  of  tincture  of  iodin  into  the  sac. 
Bonnet :  Acupuncture  in  and  about  the  sac. 
Luton:  The  injection  of  concentrated  saline  solution 

around  about  the  hernial  orifice. 
Guerin :  Subcutaneous  scarifications. 

3.  The  ligation  of  the  sac  of  the  hernia  (Celsus. — Paul  of 
.Egina,  who  was  the  first  to  recommend  castration  in  the 
operation  for  inguinal  hernia) . 

The  '"golden  ligature/'  because  the  ligation  was  made 
with  a  golden  thread  (Geraldus  von  Metz). 

The  *^  royal  ligature,"  since  it  saved  the  soldiers  for  the 
king. 

4.  The  ligation  of  the  sac  and  the  union  of  the  edges  of 
the  hernial  ring  by  means  of  sutures  (Wood). 


70  HERNIA. 

5.  The  plugging  of  the  hernial  orifice. 

Petit:  by  the  invagination  of  the  sac. 

Mdsner:  by  foreign  bodies  which  were  introduced 

into  the  hernial  orifice. 
Gerdy :  by  invagination  of  the  skin  into  the  hernial 

orifice  and  its  fixation  in  this  position  by  sutures. 
Wutzer  and  Rothmund :  by  invagination  of  the  skin 

by  means  of  special  instruments. 

Without  going  into  the  details  of  the  methods  used  in 
special  hernias,  which  will  be  fully  considered  later,  the 
curative  procedures  employed  under  the  protection  of  anti- 
sepsis may  be  divided  into  two  groups  :  first,  those  in  which 
an  attempt  is  made  to  obliterate  the  sac  by  the  injection  of 
irritating  fluids  in  its  immediate  neighborhood ;  second, 
those  in  which  an  open  operation  is  performed. 

The  first  of  these  methods  was  recommended  in  1877  by 
Schwalbe,  Avho  employed  70^  alcohol.  Although  the 
procedure  has  not  been  generally  adopted,  it  may  occasion- 
ally effect  a  radical  cure  in  young  children,  in  w^hom  there 
is  always  a  great  tendency  to  spontaneous  cure.  Since  the 
careful  execution  of  the  method  is  followed  by  no  danger, 
it  may  be  tried  in  appropriate  cases,  particularly  if  an  opera- 
tion is  not  indicated  upon  general  grounds.  [I  believe  that 
all  injection  methods  are  attended  with  some  risk,  and 
should  never  be  employed.  They  rarely,  if  ever,  effect  a 
permanent  cure,  and  often  make  the  radical  operation  more 
difficult  when  it  has  to  be  performed.  I  have  seen  one  fatal 
case  from  intestinal  obstruction  caused  by  escape  of  fluid 
into  the  abdominal  cavity,  and  formation  of  adhesions. 
Now  that  the  open  methods  are  so  safe  and  so  effective, 
and  require  but  two  weeks  in  bed,  it  is  difficult  to  see 
under  what  conditions  it  would  be  preferable  to  give  daily 


GENERAL  TREATMENT.  71 

injections  for  two  weeks,  one  week  of  wliicli  the  patient 
must  be  kept  in  bed,  and  finally  only  the  most  uncertain 
and  indiiferent  results  can  be  promised. — Ed.] 

After  the  skin  over  and  about  the  hernia  has  been  care- 
fully disinfected,  the  hernia  is  reduced  and  the  left  index- 
finjrer  is  carried  into  the  hernial  orifice  and  allowed  to 
remain  there j  in  order  to  surely  prevent  the  descent  of  the 
viscera  during  the  injection.  The  needle  of  a  hypodermic 
syringe  is  now  introduced  at  a  distance  of  1  or  2  centi- 
meters from  the  edge  of  the  hernial  orifice,  and  Avhen  no 
blood  trickles  out  of  the  needle, — a  sign  that  a  vessel  has 
not  been  punctured, — a  syringeful  of  70%  alcohol  is  in- 
jected, and  this  procedure  is  repeated  in  several  places 
about  the  neck  of  the  hernia.  The  injections  should  be 
made  daily  or  every  other  day  for  at  least  two  weeks,  later 
at  longer  intervals,  and  the  patient  should  remain  in  bed 
during  the  first  week. 

Instead  of  alcohol,  Lannelongue  recommends  the  em- 
ployment of  a  10^  zinc  chlorid  solution,  of  which  five  or 
ten  drops  are  to  be  injected  in  several  situations  about  the 
hernial  orifice. 

The  first  radical  operations  under  the  protection  of  anti- 
sepsis consisted  simply  in  the  closure  of  the  hernial  orifice 
by  suture  (Steele).  Subsequently  great  stress  was  laid 
upon  the  closure  of  the  neck  of  the  sac,  and  after  Czerny, 
in  1877,  had  pointed  out  the  rational  manner  of  perform- 
ing the  radical  operation, — since  he  taught  that  both  the 
neck  of  the  sac  and  the  hernial  orifice  should  be  closed, — 
the  way  was  clear  for  the  further  development  of  opera- 
tive procedures.  The  principle  of  the  majority  of  these 
operations  is  as  follows  :  The  sac  of  the  hernia  is  exposed 
by  an  incision  and  isolated,  this  isolation  being  most  read- 
ily accomplished  by  starting  at  the  neck  of  the  sac ;  the 


HERNIA. 


contents  of  tlie  licrnia  are  either  replaced  before  opening 
the  sac  or,  if  irreducible,  tlicy  are  subsequently  freed  from 
adliesions ;  omentum  which  has  been  in  the  sac  for  some 
time  is  usually  tied  off  in  sections  and  extirpated.     After 
the  reduction  of  the  contents,  traction  is  made  upon  the 
isolated  sac  and  a  needle  armed  with  two  catgut  ligatures 
is  passed  through  the  middle  of  the  neck  as  high  up  as 
possible.      This  step  is  to  be  carried  out  under  direct  con- 
trol of  the  eye  in  order  to  avoid  puncturing  any  of  the  vis- 
cera which  may  be  forced  down  again  at  the  last  moment. 
Ligatures  Nos.  1  and  2  are  now  tied  upon  their  respective 
sides,  and  then  the  ends  of  ligature  JN'o.  2  are  carried  about 
the  entire  neck  and  tied  just  below  ligature  JN'o.  1.     Such 
a  knot  will  never  slip,  and  the  stump,  about  one  centimeter 
in  length,  usually  retracts  into  the  abdominal  cavity  when 
the  sac  is  cut  off.     In  those  cases  in  which  the  hernial  ori- 
fice is  very  large  or  the  pressure  of  the  protruded  viscera 
is  so  great  that  a  ligation  is  impossible,  the  suture  of  the 
neck  of  the  sac  is  to  be  recommended.      In  all  cases  the 
closure  of  the  neck  of  the  sac  must  be  so  high  up  and  the 
isolation  of  the  neck  so  complete  that  no  trace  of  a  funnel- 
like diverticulum  of  peritoneum  can  be  observed.     The 
second  part  of  the  operation  is  the  closure  of  the  hernial 
orifice  by  suture.     The  patients  usually  remain  in  bed  for 
three  weeks,  and  are  then  discharged  without  a  truss,  since 
experience  has  shown  that  pressure  weakens  rather  than 
supports  the  scar. 

In  the  special  consideration  of  the  various  hernias,  we 
will  see  that  certain  hernial  orifices,  such  as  tliose  in  the 
inguinal  region,  require  rather  complicated  methods  in 
order    to   effect   their    permanent   closure.     That   such   a 


GENERAL  TREATMENT.  73 

closure  can  be  effected  is  proved  l)y  tlie  results  of  the 
modern  radical  operation,  which  may  now  be  regarded  as 
a  procedure  free  from  danger,  and  as  one  which,  with  few 
exceptions,  results  in  a  permanent  cure.  These  statements 
may  be  proved  by  extensive  series  of  statistics,  which 
include  all  the  cases  operated  upon  by  the  respective 
authors  during  a  certain  period  of  time.  Smaller  series 
of  statistics  and  reports  of  selected  cases  are  of  no  value 
in  the  solution  of  this  question,  and  consequently  will  not 
be  considered. 

Before  we  recommend  the  radical  operation  to  a  patient 
with  a  non-strangulated  abdominal  hernia,  and  tell  him 
that  the  procedure  is  safe  and  sure  in  its  results,  we  must 
know  both  the  mortality  of  the  operation  and  the  percen- 
tage of  recurrences.  AVe  consider  a  patient  free  from 
recurrence  who  has  carried  on  his  usual  occupation  for  at 
least  a  year  after  the  operation  and  who  still  remains  free 
from  any  return  of  the  hernia. 

In  order  to  obtain  a  proper  conception  of  the  present 
status  of  this  question  it  is  fitting  to  consider  the  publica- 
tions of  recent  years  only,  since  during  this  time  there  has 
been  considerable  progress  in  the  development  both  of 
asepsis  and  of  the  radical  operation.  The  following  tables 
consequently  contain  only  the  statistics  which  have  been 
published  since  1895.  The  names  in  parentheses  desig- 
nate the  method  employed  by  the  different  operators. 

It  will  thus  be  seen  that  in  5419  radical  operations  upon 
non-strangulated  hernia  there  were  28  deaths;  /.  e.,  a  mor- 
tality of  0.5^. 

The  number  of  cases  at  our  command  for  tlie  purpose  of 
determining  the  frequency  of  recurrences  is  a  much  smaller 


TABLE    SHOWING   THE    MORTALITY    AFTER    OPERATION 
FOR  NON-STRANGULATED  ABDOMINAL  HERNIA. 


Year. 

Author. 

Opera- 
tions. 

Deaths. 

Cause  of  Death. 

1895 

Nordische  Samniel- 
f  orschuufi;    ( Bas- 

sini) 

748 

10 

Two  hemorrhages,  1 
hemorrhage  and  sep- 
sis, 1  bichlorid  pois- 
oning, 1  chloroform 
poisoning,  3  degener- 
ation of  heart,  1  em- 
physema and  bron- 
chitis, 1  pneumonia. 

1895 

Beresowski  (Koclier) 

220 

0 

1896 

af    Schulten    (Bas- 

sini) 

235 

2 

One  phlegmon,  1  col- 
lapse,     pericardial 

1896 

Simon    (mostly 

adhesions. 

Czeruy)    .... 

105 

2 

One  aspiration  pneu- 
monia, 1  gangrene  of 
the  lung. 

1897 

Ludwig  (Bassini)  . 

143 

1 

Pyemia. 

1898 

Slajmer  (Wolfler)  . 

250 

0 

1898 

Lebensohn  ( Kocher) 

126 

0 

1898 

Borelius  (Bassini) 

147 

1 

Cardiac  paralysis  8  days 
after  the  operation. 

1898 

Iwensen 

102 

0 

1898 

Maydl      ..... 

190 

2 

One  pulmonary  tuber- 
culosis 17  daj^s  after 
the  operation,  1  bron- 
chopneumonia. 

1899 

Rotter  (Bassini)    , 

250 

1 

Erysipelas. 

1899 

Franz      (Bassini)  . 

100 

0 

1899 

Bnll   and  Coley 

(Bassini)     .    .    . 

917 

5 

One  double  pneumonia, 
1  peritonitis,  1  peri- 
carditis and  pneumo- 
nia, 1  omental  hem- 

1899 

Bloodgood     (Hal- 

orrhage,  1  shock. 

sted) 

395 

2 

One  diphtheritic  coli- 
tis, 1  pulmonary  em- 
bolism. 

1899 

Galeazzi    (Bassini, 

Koclier)  .... 

1400 

2 

Accidental  diseases 
having  no  connection 
with  the  operation. 

1900 

Kirschkopf  ( Koclier) 

191 

0 

Total  .    .    . 

5419 

28 

[1901,  Coley  (Bassini),  954  cases,  2  deaths. — Ed.] 

74 


GENERAL  TREATMENT.  75 

one,  since  considerable  (lifficulty  is  encountered  in  keeping 
these  cases  under  observation,  and  also  since  there  are 
always  cases  published  in  which  too  short  a  time  has 
elapsed  to  allow  us  to  form  an  opinion  of  the  definitive 
result.  In  addition  to  this,  the  material  is  not  homogen- 
eous, since  the  individual  varieties  of  hernia  behave  quite 
diiferently  in  reference  to  the  radical  cure  ;  some  authors 
have  reported  all  forms  of  hernia  together,  while  others 
record  the  results  in  but  one  definitive  variety.  At  all 
events,  the  table  on  page  76  will  furnish  a  general  idea  of 
the  frequency  of  recurrence. 

[My  personal  results  in  operations  for  the  radical  cure  of 
hernia,  up  to  the  present  time, — May,  1902, — are  as  follows : 

Of  a  total  of  954  operations,  931  were  for  inguinal  and 
femoral  hernia,  24  for  umbilical,  epigastric,  and  ventral. 
There  were  62  operations  for  femoral  hernia  ;  and  of  these, 
16  cases  were  operated  upon  by  Bassini's  method  for 
femoral  hernia,  the  remaining  46  by  the  purse-string 
method,  consisting  of  very  high  ligation  and  removal  of 
the  sac,  with  a  purse-string  suture  surrounding  the  crural 
opening  and  bringing  the  floor  of  the  crural  canal,  pectineal 
fascia,  and  muscle  into  contact  with  the  roof  of  the  lower 
border  of  Poupart's  ligament.  This  method  I  consider 
the  simplest  and  most  satisfactory  of  any  thus  far  devised, 
and  in  46  unselected  cases  in  which  I  have  used  it  in  the 
past  ten  years,  not  a  single  relapse  has  thus  far  been 
observed,  and  nearly  all  of  the  cases  have  been  traced. 
In  the  series  of  62  cases  of  femoral  hernia  only  one  re- 
lapse has  been  observed,  and  this  occurred  in  a  case  operated 
upon  according  to  Bassini's  method,  and  is  the  only  one  of 
the  series  in  which  suppuration  occurred.     The  relapse  is 


76 


HERNIA. 


SO  slight  that  it  is  scarcely  more  than  an  exaggerated 
impulse,  and  although  five  years  have  elapsed,  it  has  not 
increased  in  size  nor  been  sufficiently  large  to  need  a  truss. 

TABULATED  EEVIEW  OF  THE  NUMBER  OF  RECURRENCES 
APPEARING  AFTER  RADICAL  OPERATIONS. 


Number     of 

Cases   Subse- 

quently   Ob- 

Year. 

Author. 

serve  D    IN 
Which     at 
Least    One 
Year      Had 
Passed  Since 
THE    Opera- 
tion. 

Percentage 
OP  Recur- 
rences. 

Variety   of 
Hernia. 

1895 

Beresowsky  (Koch- 

er) 

152 

10.8  % 

All  varieties  to- 
gether. ^ 

1895 

Nicoladoni  (Bassini) 

49 

6.1   % 

Not  stated. 

1896 

af  Schulten     .    .    . 

112 

1.5  % 

All  varieties  to- 

1896 

Simon     (mostly 

gether. 

Czerny)    .... 

109 

11.9  % 

Inguinal  and  fe- 
moral hernia. 

1898 

Slajmer  (Wolfler)  . 

76 

9.2  % 

Inguinal  hernia. 

1898 

Lebensohn  (Kocher) 

83 

4.8  % 

Inguinal  hernia. 

1898 

Brenner  (modifica- 

tion of  Bassini)  . 

169 

5.9  % 

Inguinal  hernia. 

1898 

Bull    and   Coley 

(Bassini)     .    .    . 

618 

1.9  % 

Not  stated. 

1899 

Franz  (Bassini) 

31 

6.4  % 

Inguinal  hernia. 

1899 

Galeazzi    ( Bassini , 

Kocher)   .... 

840 

5.71% 

Inguinal  hernia. 

1900 

Hirschkopf  ( Kocher) 

83 

1.2  % 

Inguinal  and  fe- 
moral hernia. 

1901 

Coley  (Bassini)  .    . 

531  (500  in- 

1.3 % 

Inguinal      and 

guinal  and 

(7  relapses) 

femoral. 

31  femoral) 

^This  number  was  obtained  from  the  following  statement  of  Bere- 
sowsky : 

E.xterual  inguinal  hernia,      I  method  of  operation  :  64  cases  with  6  recurrences 

II        "         «  «  32      «         u     2 

III        <<         «  <<  22 

Femoral  hernia 13 

Internal  inguinal  hernia    12 

Umbilical,  epigastric,  and  ventral  hernia 10 


0 

1  recurrence. 

2  recurrences. 
3 


153  cases  with  14  recurrences 

=10.81 


GENERAL  TREATMENT.  77 

Of  the  869  cases  of  inguinal  hernia,  851  were  operated 
upon  by  Bassini's  method  with  the  su])stitution  of  kangaroo 
tendon  for  silk  in  all  the  buried  sutures.  But  seven 
relapses  have  been  observed,  although  upward  of  500 
cases  have  been  traced  for  periods  of  one  to  nine  years. 
—Ed.] 

This  table  shows  the  great  improvement  in  the  number 
of  permanent  results  obtained  within  the  last  three  years. 
The  largest  number  of  recurrences  after  operations  for 
inguinal  and  femoral  hernia  was  9.2^,  while  other  authors 
reported  still  smaller  percentages,  some  being  as  low  as 
1.2^0'  AVe  can  conscientiously  claim  that  in  the  over- 
whelming majority  of  cases  of  abdominal  hernia  the  radi- 
cal operation  is  able  to  eifect  a  permanent  cure.  Accord- 
ing to  the  computations  of  Bull  and  Coley,  the  majority 
of  recurrences  appear  Avithin  the  first  year  :  64.5^  occur 
during  the  first  six  months,  80  ^  during  the  first  year, 
20  fo  after  the  first  year,  and  of  the  total  almost  9  fo  made 
their  appearance  between  the  first  and  second  year  after 
the  operation. 

Since  the  operation  is  not  a  dangerous  one,  the  indica- 
tions for  the  procedure  may  be  given  a  considerable  lati- 
tude. We  are  justified  in  performing  the  operation  not 
only  in  patients  who  suffer  considerable  annoyance  from 
their  hernias  (irreducible  hernia,  strangulated  hernia),  or 
in  whom  a  truss  cannot  be  properly  applied,  but  also 
regarding  as  a  sufficient  indication  the  wish  of  the  patient 
to  be  emancipated  from  his  truss  and  the  danger  of  even- 
tual strangulation.  The  only  questions  are  whether  the 
operation  is  contraindicated  in  the  very  young,  in  the  very 
old,  or  bv  an  enormous  size  of  the  hernia. 


78  HERNIA. 

The  fear  of  operating  in  very  young  children  has  disap- 
peared since  we  have  learned  that  the  mortality  is  no 
greater  than  among  adults.  However,  since  experience 
teaches  that  no  small  number  of  the  hernias  of  childhood 
are  spontaneously  cured  with  advancing  age,  we  regard 
the  operation  as  indicated  in  those  cases  only  in  which  the 
treatment  by  means  of  a  truss  cannot  be  carried  out.  In 
very  young  children  great  care  must  be  exercised  to  pre- 
vent the  infection  of  the  wound  with  feces  and  urine. 
Thick  absorbent  dressings  which  come  in  close  relation- 
ship with  the  anal  and  urethral  orifices  should  not  be 
employed,  but  the  wound  is  to  be  accurately  sealed  up 
with  as  limited  a  dressing  as  possible.  This  is  to  be 
accomplished  by  painting  the  sutured  wound  with  airol 
paste  ^  or  zinc  paste,  ^  applying  some  sterile  gauze,  and 
strapping  on  the  small  dressing  with  an  abundance  of 
rubber  adhesive  strips.  [The  dressing  that  I  have 
uniformly  employed  the  past  ten  years  has  been  10^ 
iodoform  gauze,  with  moist  1  :  5000  bichlorid  gauze, 
held  in  place  by  rubber  adhesive  plaster.  Over  this 
is  placed  absorbent  cotton  and  three  firmly  applied 
bandages  of  gauze  and  muslin.  In  all  of  the  chil- 
dren, more  than  five  hundred  in  number,  I  have  also 
applied  a  plaster-of- Paris  spica  extending  from  chest  to 
below  the  knee.  I  do  not  believe  in  the  small  dressing  or 
in  sealing  the  wounds.  The  moist  dressing  absorbs  the 
slight  exudate,  and  I  have  had  one  series  of  200  cases 
with  but  a  single  suppuration. — Ed.] 

^  Airol,  5.0  (gr.  Ixxv);  Mucil.  acacise,  Glycerinte,  aa  10.0  (^iiss). 
Bol.  alb.  qu.  sat.  ut  fiat  pasta  mollis. 

2  Zinci  oxidi,  Mucil.  acacise,  Glycerinae,  aa  20.0  (  X  v).  Bol.  depur. 
40.0  (  3  x).     M.     Ft.  pasta. 


GENERAL  TEEAT3IENT.  79 

In  aged  patients  the  conditions  are  diiFerent ;  the  narco- 
sis itself  is  not  a  harmless  procedure,  and  the  forced  rest 
in  bed  after  the  operation  favors  the  appearance  of  stasis 
in  the  lungs,  from  Avhich  a  hypostatic  pneumonia  frequently 
develops.  Those  patients  who  already  have  a  chronic 
bronchitis  are  particularly  endangered.  In  an  individual 
case  we  could  say,  in  a  general  way,  that  in  persons  over 
sixty  years  of  age  the  radical  operation  of  a  reducible 
hernia  should  be  performed  only  when  the  symptoms  pro- 
duced by  the  hernia  are  quite  annoying,  and  that  it  is  con- 
traindicated  if  marked  arteriosclerosis  or  bronchitis  are 
demonstrable,  or  where  there  is  general  debility  from  defi- 
cient cardiac  activity. 

Is  the  enormous  size  of  a  hernia  a  contraindication  to 
the  radical  operation  ?  Kramer  has  undertaken  the  meri- 
torious task  of  reviewing  the  publications  upon  this  point, 
and  comes  to  the  conclusion  that  even  with  the  perfected 
asepsis  of  to-day,  the  radical  operation  of  unusually  large 
hernias  is  associated  with  no  small  danger  to  life,  the 
danger  being  proportionate  to  the  size  of  the  hernia.  The 
explanation  of  this  is  to  be  found  in  the  extent  of  the 
w^ound  and  in  the  different  manipulations  and  attempts  at 
reduction  which  must  be  undertaken  upon  a  large  mass  of 
viscera.  The  statistics  collected  by  Kramer  also  show  that 
patients  affected  ^vith  complications  have  borne  the  oper- 
ation badly,  particularly  decrepit  individuals  suffering 
from  chronic  alcoholism  or  obesity,  or  those  with  diseases 
of  the  respiratory,  circulatory,  or  urinary  organs.  It  con- 
sequently follows  that  a  patient  with  a  very  voluminous 
hernia  should  be  subjected  to  a  most  thorough  examination 
before  the  operation  is  attempted. 


80  HERNIA. 

In  every  case  of  radical  operation  the  patient  must  be 
carefully  prepared  for  the  procedure.  Jn  order  to  obtain 
the  most  favorable  results  the  individual  must  be  bathed, 
and  on  the  day  preceding  the  operation  the  hernial  region 
is  to  be  shaved,  thoroughly  scrubbed,  and  then  covered  by 
gauze  saturated  with  a  1  :  2000  solution  of  bichlorid. 
The  intestines  must  be  sufficiently  emptied,  since  the  neces- 
sary cleanliness  of  the  dressings  makes  it  desirable  that 
there  should  be  no  movement  of  the  bowels  during  the 
first  few  days  after  the  operation.  This  evacuation  of  the 
bowels  is  of  special  importance  if  the  hernia  is  large  and 
irreducible,  since  it  aids  materially  in  the  reposition  of  the 
hernial  contents.  While  a  patient  with  a  small  reducible 
hernia,  who  does  not  suffer  from  constipation,  is  sufficiently 
prepared  in  a  day  by  a  single  dose  of  castor  oil,  the  pre- 
paration in  other  cases  must  extend  ever  several  days, 
during  which  the  patient  receives  only  a  liquid  diet,  purga- 
tives by  the  mouth,  and  large  enemata  by  the  rectum. 


THE  ACCIDENTS  OF  HERNIA, 

A  hernia  renders  a  patient  liable  to  certain  dangers 
which  may  at  any  time  make  their  appearance,  either  sud- 
denly or  gradually,  and  which  are  designated  as  the  acci- 
dents of  hernia.  Under  this  heading  are  usually  included  : 
(1)  The  accumulation  of  feces  and  obstruction  of  the  intes- 
tine situated  within  the  hernial  sac ;  (2)  inflammation  ; 
and  (3)  strangulation. 

It  was  formerly  believed  that  the  accumulation  of  feces 
played  a  much  more  important  role  than  we  now  know  to 
be  the  case.     In  a  large  irreducible  hernia  where  peristal- 


A  CCI DENTS  OF  HERNIA .  8 1 

sis  is  hindered  by  the  changed  rehition.s,  and  probably  also 
by  adhesions,  it  may  seem  plansible  that  the  passage  of 
feces  is  disturbed  and  that  the  intestinal  contents  must 
consequently  become  obstructed,  but  such  cases,  in  which 
symptoms  are  produced  resembling  those  of  strangulation, 
and  which  are  to  be  unequiv^ocally  explained  in  this  man- 
ner, are  extremely  rare.  Since  fecal  stasis  in  a  non-strang- 
ulated hernia  could  only  be  caused  by  solid  fecal  masses, 
only  hernias  of  the  large  intestine  would  come  under  dis- 
cussion, and  this  in  itself  would  place  a  marked  limitation 
upon  the  frequency  of  the  occurrence.  In  a  markedly 
constipated  patient  with  a  hernia  of  the  large  intestine,  it 
is  easily  understood  that  an  engorgement  of  the  intestinal 
loop  within  the  hernial  sac  may  occur,  making  the  consti- 
pation more  obstinate,  and  causing  the  patient  no  small 
amount  of  annoyance,  but  it  is  extremely  rare  that  a 
strangulation  Avould  develop  from  such  a  pure  fecal  stasis 
— an  occurrence  which  Avas  formerly  almost  universally 
accepted. 

Fecal  stasis  in  the  herniated  loop  is  to  be  combated  by 
purgatives,  by  intestinal  irrigation,  and  particularly  by 
direct  manipulation  of  the  hernia.  If  the  hernia  is  reduci- 
ble, evacuation  will  be  more  easily  accomplished,  after  the 
reposition,  if  the  intestines  are  permanently  held  within 
the  abdomen  by  the  immediate  application  of  a  truss  or  a 
substitute  in  the  shape  of  a  large  pad  of  cotton.  The 
treatment  of  fecal  stasis  in  a  large  irreducible  hernia  is 
more  difficult,  and  in  these  cases  the  desired  end  is  best 
attained  by  attempting  to  empty  the  intestinal  coils  by 
manual  compression  of  the  entire  hernia.  A  single  attempt 
is  not  always  successful,  and  sometimes  the  condition  is  not 
6 


82  HERNIA. 

overcome  until  systematic  daily  massage  has  been  prac- 
tised, and,  the  size  of  the  tnmor  permitting,  its  envelop- 
ment in  elastic  bandages  in  the  interval. 

Inflammation  of  a  hernia  is  a  never-failing  concomi- 
tant of  strangulation,  occurs  not  infrequently  as  an  inde- 
pendent affection,  and  can  produce  a  grave  clinical  picture. 
The  symptoms  sometimes  have  a  striking  similarity  to  those 
of  strangulation,  but  there  are  nevertheless  clearly  pro- 
nounced cases  in  which  the  diagnosis  can  be  easily  made. 
The  tendency  of  the  peritoneal  surfaces  to  become  adher- 
ent or  form  exudates  when  subjected  to  slight  irritation  is 
retained  both  by  the  sac  of  the  hernia  and  also  by  the  peri- 
toneal covering  of  the  abdominal  viscera.  The  peritoneum 
is  so  sensitive  that  even  slight  disturbances  of  the  circula- 
tion may  result  in  a  reactive  inflammation.  A  slight  com- 
pression of  the  omental  or  mesenteric  vessels,  without  the 
existence  of  constriction,  or  the  weight  of  a  heavy  hernia 
is  frequently  sufficient  to  cause  slight  venous  stasis  and  the 
formation  of  a  minimum  amount  of  exudate,  which  leads 
to  agglutinations  and  adhesions  in  the  hernial  contents  and 
between  the  contents  and  the  sac.  Such  adhesions  can  also 
be  caused  by  external  pressure,  such  as  that  produced  by 
a  truss  which  has  been  applied  while  a  tip  of  omentum  was 
still  within  the  hernial  sac.  Those  hernias  which  have 
been  incarcerated  one  or  more  times  are  particularly 
inclined  to  the  formation  of  adhesions. 

It  has  previously  been  mentioned  that  adhesions  of  the 
hernial  sac  may  cause  its  obliteration,  and  the  spontaneous 
cure  of  the  hernia  or  the  formation  of  cysts  and  diverticula. 
The  mildest  form  of  inflamed  hernia  may  be  recognized  by 
the  fact  that  the  hernia  which  previously  was  freely  mov- 


ACCIDENTS  OF  HERNIA.  83 

able  now  becomes  irreducible,  partly  from  adhesions  between 
the  contents  and  the  sac,  and  partly  from  the  formation  of 
large  convolutions  of  adherent  omentum  and  loops  of  intes- 
tine which  can  no  longer  be  returned  through  the  much 
narrower  hernial  orifice. 

Exudates  in  the  hernial  sac  may  be  due  to  a  primary 
inflammation  in  this  situation  or  to  an  inflammation  origi- 
nating within  the  peritoneal  cavity  or  in  the  vicinity  of  the 
hernia.  Like  those  of  the  peritoneum,  the  exudates  pro- 
duced by  the  inflammation  of  a  hernia  may  be  serous, 
fibrinous,  or  purulent.  If  from  any  cause  a  purulent  in- 
flammation of  the  peritoneum  spreads  to  the  hernial  sac, 
the  symptoms  of  inflamed  hernia  are  forced  into  the  back- 
ground by  the  graver  symptoms  of  the  peritonitis.  In  the 
same  manner,  if  a  chronic  inflammation,  such  as  tubercu- 
losis, extends  to  the  sac,  the  symptomatology  is  dominated 
by  the  general  inflammation  of  the  peritoneum.  The  con- 
ditions are  diflferent  if  the  inflammatory  process  is  inde- 
pendent of  the  peritoneal  cavity,  developing  in  the  sac 
primarily  or  extending  to  it  from  some  inflammation,  such 
as  a  phlegmon,  of  the  hernial  surroundings.  Serous  in- 
flammation, as  the  name  indicates,  leads  to  the  formation 
of  a  serous,  clear,  yellowish  exudate,  which  is  shut  oif  from 
the  peritoneal  cavity  by  more  or  less  firm  adhesions.  If 
the  exudate  arises  in  an  empty  hernial  sac  closed  upon  all 
sides,  we  have  a  cyst,  a  form  of  hydrocele,  with  the  symp- 
toms of  dulness  on  percussion,  transparency,  no  increased 
protrusion  with  augmentation  of  the  intra-abdominal  pres- 
sure, and  usuallv  some  tenderness.  Whether  such  a  cvst 
may  be  lifted  up  from  the  abdominal  wall,  like  a  hydrocele 
of  the  testicle,  depends  upon  the  situation  of  the  adhesion 


84  HERNIA. 

in  the  neck  of  the  sac.  If  there  are  contents  within  the 
hernial  sac,  the  exudate  becomes  apparent  as  an  increased 
amount  of  hernial  fluid. 

Fibrinous  inflammation,  characterized  by  fibrinous  de- 
posits upon  the  surface  of  the  herniated  viscera  and  of 
the  sac,  is  the  chief  form  which  rapidly  produces  agglu- 
tinations and  firm  adhesions.  It  more  frequently  appears 
in  combination  with  a  fluid  exudate  as  a  serofibrinous 
inflammation. 

Purulent  inflammation  is  the  most  severe  form,  and  is 
produced  by  the  presence  of  pathogenic  micro-organisms. 
Disregarding  their  direct  migration  from  neighboring  foci 
of  suppuration,  the  source  of  the  bacteria  is  easily  ex- 
plained if  portions  of  the  intestine  are  in  the  hernial  sac 
and  have  been  subjected  to  circulatory  disturbances  or  to 
inflammation,  such  as  bruising  by  attempts  at  taxis,  intes- 
tinal ulceration,  or  perityphlitis.  Under  such  conditions 
the  bacteria  may  pass  directly  through  the  damaged  intes- 
tinal wall  into  the  hernial  sac  and  give  rise  to  suppuration. 
What  is  the  source  of  the  pyogenic  organisms,  however, 
when  the  sac  is  empty  or  contains  nothing  but  omentum  ? 
As  the  occasional  suppurations  occurring  in  subcutaneous 
extravasations  of  blood  or  in  uncomplicated  fractures  are 
to  be  explained  by  the  favorable  conditions  for  growth 
offered  to  isolated  bacteria  circulating  in  the  blood  and 
coming  from  an  angina  or  from  a  furuncle,  we  must  sup- 
pose, in  the  present  instance,  that  the  power  of  resistance 
of  the  abdominal  hernia  to  pyogenic  organisms  is  dimin- 
ished by  some  preceding  injury,  so  that  the  bacteria  find 
more  favorable  conditions  for  development. 

These  different  varieties  of  inflammation  may  frequently 


ACCIDENTS  OF  HERNIA.  85 

be  combined,  a  hernial  inflammation  commencing  as  a 
serous  type,  becoming  serofibrinous,  and  ending  as  a  puru- 
lent form.  Upon  the  other  hand,  the  inflammation  may 
be  arrested  at  any  part  of  the  process  or  be  a  severely 
purulent  one  from  the  beginning  without  passing  through 
the  milder  stages. 

The  symptoms  of  the  mildest  form  of  inflamed  hernia 
are  so  slight  that  they  are  usually  unnoticed.  Adhesions 
are  formed  so  slowly  and  painlessly  that  their  presence  is 
first  manifested  by  the  consequent  irreducibility  of  the 
hernia.  Some  of  the  symptoms  of  serous  inflammation 
have  already  been  mentioned.  In  addition  to  the  presence 
of  a  collection  of  fluid,  and  frequently  of  a  moderate 
amount  of  tenderness,  it  often  happens  that  there  is  an 
absence  of  all  of  the  general  irritative  peritoneal  symptoms 
which  we  will  presently  learn  to  recognize  in  the  purulent 
inflammation. 

It  is  usually  stated  that  fibrinous  inflammation  may  be 
recognized  by  the  presence  of  crepitation,  which  is  felt 
when  the  skin  over  the  hernia  is  removed,  and  which  is 
due  to  the  rubbing  of  contiguous  fibrin-covered  surfaces 
of  peritoneum  and  to  the  breaking-up  of  adhesions.  I  do 
not  w^ish  to  place  too  much  stress  upon  this  symptom, 
since  its  absence  does  not  preclude  the  existence  of  the 
condition. 

The  purulent  inflammation  of  a  hernia  produces  severe 
symptoms,  and  is  the  one  which  most  resembles  strangula- 
tion. There  is  usually  a  general  febrile  reaction,  the  local 
swelling,  tension,  and  tenderness  become  more  marked, 
the  overlying  skin  may  be  reddened,  and — most  pronounced 
of  all — there  are  symptoms  of  peritoneal  irritation.     This 


86  HERNIA. 

irritation  is  manifested  by  pain  radiating  from  the  hernia 
over  the  entire  abdomen^  by  the  appearance  of  nausea, 
eructation,  and  vomiting,  and  by  a  more  or  less  complete 
paralysis  of  the  bowel,  in  consequence  of  which  the  pas- 
sage of  feces  and  flatus  is  markedly  diminished.  The 
condition  differentiates  itself  from  diffuse  peritonitis  in  the 
following  respects  :  the  abdomen  is  soft,  not  tender  or 
tympanitic,  the  signs  of  general  sepsis  are  absent  since  the 
tongue  remains  moist,  the  pulse  is  neither  small  nor 
markedly  accelerated,  and  the  urinary  secretion  is  practi- 
cally undiminished. 

The  difference  between  the  purulent  inflammation  of  a 
hernia  and  intestinal  strangulation  is  as  follows  :  in  the 
hernial  inflammation  the  closure  of  the  bowel  produced  by 
the  intestinal  paralysis  is  frequently  incomplete,  usually 
allowing  the  passage  of  gas  at  least,  and  painful  visible 
peristaltic  movements  of  the  intestine  on  the  proximal  side 
of  the  hernia  are  absent.  There  are,  nevertheless,  some 
cases  in  which  the  differentiation  is  difficult,  and  if  there 
is  the  slightest  doubt,  the  case  must  be  treated  as  though 
the  graver  condition — i.  e.,  a  strangulation — were  present. 

The  milder  forms  of  inflamed  hernia  ordinarily  pursue 
a  favorable  course,  since  the  inflammation  shows  no  ten- 
dency to  spread  to  the  general  peritoneum.  The  symp- 
toms slowly  disappear,  the  exudate  is  absorbed,  and 
adhesions  are  left  behind.  In  some  cases  the  inflamma- 
tion may  be  followed  by  strangulation  if  the  neck  of  the 
hernial  sac  has  been  thickened  and  narrowed. 

If  the  purulent  inflammation  is  not  treated,  it  spreads 
to  the  surrounding  tissues.  In  favorable  cases  the  inflam- 
mation extends  to   the  hernial   coverings  and   perforates 


ACCIDENTS  OF  HERNIA.  87 

externally,  while  in  unfavorable  cases  the  peritoneal  cavity 
becomes  infected  and  a  peritonitis  develops  which  threat- 
ens tlie  life  of  the  patient. 

The  treatment  is  governed  by  the  severity  of  the  inflam- 
mation. In  the  serous  form  an  attempt  may  be  made  to 
arrest  the  inflammation  and  possibly  to  reduce  the  hernia  by 
rest  in  bed  and  the  application  of  an  ice-bag.  If  there  is 
a  suspicion  that  the  exudate  is  purulent,  the  great  danger 
of  infection  makes  any  attempt  at  reduction  inadmissible. 
Here,  as  in  every  case  in  which  strangulation  cannot  be 
absolutely  excluded,  the  only  treatment  to  be  considered  is 
free  incision  of  the  hernial  tumor,  the  most  rigid  asepsis 
being  observed.  If  the  process  has  not  already  extended 
to  the  general  peritoneum,  the  escape  of  the  pus  and  the 
maintenance  of  drainage  will  lead  to  a  rapid  recovery. 

Strangulation. — By  the  strangulation  of  a  hernia  we 
mean  such  a  firm  constriction  of  a  herniated  viscus  that 
the  constricted  portion  cannot  be  reduced,  that  disturb- 
ances of  circulation  make  their  appearance  and  may  end 
in  gangrene,  and  that  if  the  contents  of  the  hernia  consist 
of  intestine  the  passage  of  feces  and  gas  is  prevented.  In 
the  majority  of  cases  the  constricting  ring  is  formed  by 
the  hernial  orifice,  but  it  may  be  situated  in  the  neck  of 
the  sac  alone. 

In  spite  of  manifold  investigations  there  is  even  at  the 
present  time  a  lack  of  general  agreement  as  to  the  nature 
of  the  mechanism  of  strangulation.  The  difficulty  in 
giving  an  explanation  which  is  not  open  to  some  objection 
is  due  to  the  fact  that  it  is  impossible  to  artificially  produce 
a  strangulated  hernia  in  an  animal  and  have  all  the  condi- 
tions correspond  to  those  in  the  human  subject. 


88  HERNIA. 

According  to  their  origin,  two  varieties  are  diiferentiated 
— elastic  strangulation  and  fecal  strangulation. 

Elastic  Strangulation. — The  eiFects  of  elastic  strang- 
ulation are  easily  understood.  A  loop  of  intestine  is 
forced  into  the  hernial  sac  by  some  marked  augmentation 
of  the  intra-abdominal  pressure,  such  as  violent  cough, 
and  is  subjected  to  the  elastic  constriction  of  the  narrow 
hernial  orifice,  which  has  been  momentarily  dilated  by  the 
increase  of  the  abdominal  tension.  If  the  constriction  is 
moderate  and  the  orifice  not  too  small,  at  first  only  the 
venous  return  is  impeded  and  the  constricted  portion 
becomes  the  seat  of  venous  stasis.  The  intestinal  loop 
takes  on  a  dark  bluish  and  later  a  bluish-black  color, 
small  subserous  effusions  of  blood  make  their  appearance, 
and  there  is  also  an  edematous  infiltration  of  the  intestinal 
wall,  so  that  the  disproportion  between  its  size  and  that  of 
the  hernial  orifice  constantly  increases.  At  the  same  time 
there  is  a  transudation  of  fluid  into  the  sac,  and  this 
hernial  fluid,  which  in  the  beginning  is  yellowish,  clear, 
and  serous  in  character,  soon  takes  on  a  slightly  bloody 
tinge.  If  the  constriction  continues,  the  intestine  loses 
its  moist,  smooth,  glistening  appearance,  becomes  dry  and 
lusterless,  and  small  amounts  of  fibrin  are  deposited  upon 
its  surface.  The  nutrition  of  the  intestinal  coil  suffers, 
and  it  may  happen  that  the  mucosa  is  already  necrotic  at 
a  time  when  the  serosa  is  still  nourished  (Fig.  22).  The 
possibility  of  the  existence  of  such  a  condition  is  of  the 
utmost  importance  for  the  question  of  reduction.  Under 
the  further  influence  of  the  strangulation,  the  intestinal 
coil  becomes  grayish-black,  then  dirty  gray  in  color,  and 
loses  a  great  deal  of  its  tonus  and  elasticity.     The  walls 


ACCIDENTS  OF  HERNIA.  89 

of  the  intestine  feel  relaxed  and  thinned — the  coil  has 
become  gangrenous.  In  the  mean  time  the  hernial  fluid 
has  changed  in  character ;  it  has  become  cloudy  and  taken 
on  a  distinct  fecal  odor,  although  this  odor  may  be  present 
even  when  the  coil  is  not  gangrenous. 

Long  since  Garre  supposed  that  bacteria  did  not  pass 
out  from  the  intestine  until  necrosis  supervened,  and  recent 
investigations  have  shown  that  the  hernial  fluid  is  almost 
always  sterile,  in  some  instances  even  after  a  period  of 
strangulation  lasting  five  days  (Sehloffer).  In  fact,  the 
hernial  fluid  does  not  contain  living  germs  capable  of  devel- 
opment in  every  case  of  gangrene  of  the  intestine  (Tietze). 
We  consequently  have  a  right  to  suppose  that  the  hernial 
fluid  possesses  bactericidal  properties.  These  findings  have 
nevertheless  met  with  some  contradiction.  Boennecken, 
and  subsecjuently  Brentano,  came  to  the  conclusion  that 
bacteria  may  be  demonstrated  in  the  hernial  fluid  much 
oftener  than  was  supposed  by  the  previous  authors.  In  31 
strangulated  hernias,  Brentano  found  micro-organisms  in 
21  instances,  and  explained  his  result  by  the  nature  of  his 
method  of  investigation.  Several  cubic  centimeters  of  the 
fluid  must  be  taken  and  bouillon  employed  as  the  culture- 
medium. 

Perforation  finally  occurs  through  the  necrotic  intestinal 
wall,  and  there  are  two  seats  of  predilection.  The  first  of 
these  is  at  the  seat  of  constriction,  and  particularly  oppo- 
site the  mesentery  of  the  afferent  intestine,  since  this  por- 
tion of  tlie  coil  is  exposed  to  the  greatest  amount  of  pres- 
sure. The  location  second  in  frequency  is  the  convex  side 
of  the  coil,  because  this  portion  is  subjected  to  the  greatest 
tension  and  is  the  furthest  removed  from  the  nutritive 
vessels  (Fig.  21). 

If  the  elastic  compression  is  so  marked  that,  in  addition 
to  the  venous  return,  the  arterial  supply  is  also  obstructed. 


Fig,  21. — A  strangu- 
lated coil  of  intestine, 
which  has  been  resected 
on  account  of  gangrene. 
The  dilated  afferent  (a) 
and  the  collapsed  effer- 
ent (b)  ends  of  the  coil 

are  observed,  and   also  C 

two  perforations  (c)  at  the  seats  of  predilection,  a  small  one  at  the 
site  of  the  constriction  of  the  afferent  intestine  and  a  large  one  upon 
the  convex  side  of  the  coil. 


<~<»*<mw*»»«r<Kt*'^*?S^^ 


■»•. 


Fig.  22. — A  longitudinally  incised  coil  of  intestine  resected  on  ac- 
count of  gangrene  after  three  days  of  strangulation.  At  the  time  of 
operation  only  a  yellowish-gray  necrotic  area,  about  the  size  of  a  small 
bean,  was  observed  upon  the  external  surface  of  the  coil,  although 
when  the  resected  coil  was  cut  open,  as  shown  in  the  illustration,  it 
was  found  that  the  entire  mucous  membrane  hud  sloughed  away  with 
the  exception  of  small  "rests." 

90 


A  CCI DENTS  OF  HERNIA .  9 1 

the  changes  in  the  intestinal  coil  are  quite  different. 
Under  these  circumstances  a  few  hours  may  suffice  for  the 
development  of  an  anemic  necrosis  of  the  intestine  which 
has  been  completely  robbed  of  its  blood-supply.  Since 
neither  venous  stasis  nor  exudation  is  possible  in  the  intes- 
tinal wall,  the  coil  remains  pale,  thin,  and  relaxed,  and 
finally  assumes  a  uniform  yellow  color.  For  the  reasons 
previously  stated  there  is  also  an  absence  of  hernial  fluid, 
and  the  necrotic  intestinal  coil  lies  in  close  contact  with  the 
hernial  sac.  In  contrast  to  the  previously  described  case, 
in  which  the  strangulation  was  less  marked  and  in  which 
the  necrosis  was  limited  to  definite  parts  of  the  intestinal 
wall,  the  coil  of  intestine  in  this  instance  becomes  gan- 
grenous throughout.  As  in  all  varieties  of  intestinal  ob- 
struction, the  intestinal  contents  are  dammed  up  in  the 
afferent  intestine,  which  becomes  more  and  more  dilated, 
while  the  intestine  below  the  seat  of  strangulation  is 
empty,  collapsed,  and  therefore  apparently  narrowed. 

Fecal  Strangulation. — In  contrast  to  the  preceding 
variety,  there  is  a  kind  of  strangulation  in  which  the  in- 
testinal coil  within  the  sac  becomes  blocked  from  the  fact 
that  intestinal  contents  are  suddenly  forced  into  it  by  a 
marked  augmentation  of  the  intra-abdominal  pressure.  It 
is  not  necessarily  hardened  feces  which  produces  this  result, 
but  almost  always  fluid  intestinal  contents  mixed  with  gas. 
This  is  the  form  of  strangulation  which  is  so  difficult  of  a 
mechanical  explanation  and  the  correct  interpretation  of 
which  has  been  prevented  by  our  inability  to  exactly  re- 
produce the  condition  in  the  lower  animals.  It  is  called 
fecal  strangulation. 

A  number  of  meritorious  investigators   have   tried   to 


92 


HERNIA. 


solve  the  question  experimentally^  and  their  labors  have 
rendered  certain  plienomena  more  intelligible,  although  it 

cannot  be  claimed  that  the 
process  as  a  Avhole  has  been 
thoroughly  and  satisfacto- 
rily explained. 

Figure  23  illustrates  the 
experiment  performed  by 
Roser  (1856).  A  hole  about 
one  centimeter  in  diameter 
is  made  in  a  board  and  an 
intestinal  coil  filled  with 
fluid  and  gas  is  drawn 
through  the  orifice.  The 
edges  of  the  orifice  do  not 
compress  the  intestinal  coil 
and  the  opening  in  the 
board  may  be  so  large  that 
a  catheter  can  also  be  passed 
through  it  alongside  of  the 
intestinal  coil.  If  pressure 
is  suddenly  exerted  upon 
the  convexity  of  the  coil, 
the  intestine  becomes  quite 
tense,  but  the  intestinal 
contents  cannot  be  forced 
through  the  orifice,  although 
more  fluid  can  be  injected 
into  the  coil  from  the  in- 
testine on  the  other  side  of 
the  constriction,  and  al- 
though a  free  space  may  be 
seen  within  the  orifice  when 
the  intestinal  coil  is  held  to 
one  side.  Roser  thought 
that  this  closure  was  brought  about  by  the  valve-like  ac- 
tion of  the  folds  of  mucous  membrane  in  the  immediate 


Fig.  23. — Roser's  strangulation 
experiment. 


ACCIDENTS  OF  HERNIA. 


93 


vicinity  of  the  orifice,  and  that  they  acted  hke  the  semi- 
huiar  valves  in  the  aorta. 

Busch  (1875)  in  his  first  experiment  drew  an  intestinal 
coil  through  an  orifice  and  filled  the  coil,  through  the 
afferent  intestine,  with  fluid  under  strong  pressure.     He 


V. 


'^ 


Fig.  24. — Busch's  strangulation  experiment  Xo.  1. 


found  that  there  was  an  excess  of  pressure  upon  the  greater 
or  convex  intestinal  wall,  in  consequence  of  which  the 
efferent  intestine  was  drawn  down  as  far  as  its  mesentery 
would  allow,  and  that  it  then  suffered  an  angulation  which 


94 


HERNIA. 


completely  closed  its  lumen.  When  the  injection  of  fluid 
was  continued,  the  afferent  end  also  became  angulated. 
Figure  24  illustrates  the  manner  of  performing  the  experi- 
ment, the  tensely  injected  intestinal  coil,  and  the  collapsed 
efferent  intestine. 

Lossen  (1875)  modified  this  experiment  by  using  a 
hardening  wax  injection,  and  from  the  solid  cast  he  came 
to  the  conclusion  that  it  was  not  the  supposed  angulation 
of  Busch  which  caused  the  closure,  but  that  the  afferent 
intestine,  distended  by  a  thick  column  of  feces  (Fig.  25,  a), 

together  with  the  mesen- 
tery, compressed  the  effer- 
ent end  of  the  coil  (6). 
This  compression,  more- 
over, would  also  be  ex- 
erted upon  the  mesenteric 
veins,  causing  venous  sta- 
sis, and  the  consequent 
edema  would  also  encroach 
then  upon  the  afferent  end 
of  the  coil  and  finally  ef- 
fect its  complete  closure. 

In  order  to  entirely  ex- 
clude the  possibility  of 
such  a  compression  as 
that  indicated  by  Lossen, 
Busch  performed  a  second 
experiment.  He  intro- 
duced a  metal  tube  of  the 
diameter  of  a  female  cath- 
eter into  a  piece  of  intestine  and  secured  it  in  this  posi- 
tion by  means  of  a  thread  passed  through  the  mesentery 
and  tied  about  the  intestine  (Fig.  26).  ''If  the  foreign 
body  is  now  withdrawn,  the  intestinal  canal  is  greatly 
narrowed  by  the  thread,  but  its  lumen  still  exists,  since 
the  catheter  may  be  again  carried  through  the  narrow 
place  from  the  peripheral  side.  If  fluid  or  air  is  now 
rapidly  forced  into  the  intestine  from  a  point  some 
distance  above  the  ligature,  not  a  drop  of  liquid  nor  a 
bubble  of  air  will  pass  the  stenosis."     The  reason  for  this 


Fig.  25. 


Fig.  26. 


Fig.  27. — Bxisch's  strangulation  experiment  No.  2. 

95 


96 


HERNIA. 


is  not  to  be  found  in  any  valve  or  fold  upon  the  interior 
of  the  intestine,  but  the  result,  as  in  his  first  experiment, 
is  due  to  the  effect  of  the  h3^drostatic.  pressure.  The 
convex  side  of  the  intestine  is  subjected  to  a  greater  pres- 
sure than  is  the  concave  or  mesenteric  surface,  ''  the  pres- 
sure causes  the  intestine  to  straighten  upon  its  convex  side, 
and  the  convexit}^,  moving  in  this  direction,  pulls  the 
lower  portion  of  the  intestine  through  the  stenotic  ring  in 
such  a  manner  that  the  intestinal  walls  are  pressed  to- 


Fig.  28   (a). — Injection  above  Fig.  28  (b). — Injection  under 

the  stenosis  under  slight  pressure;      greater  pressure;  the  passage  is 
no  fluid  escapes.  free. 


gether."  Figure  27  shows  the  tense  injection  of  the  intes- 
tine above  the  ligature  and  the  collapsed  portion  below  it. 

Bidder  (1875)  concluded  from  his  experiments  that  the 
theories  of  Lossen  and  of  Busch  were  wrong,  and  that  the 
old  view  of  Roser  in  reference  to  the  origin  of  intestinal 
strangulation  was  entirely  correct. 

Kocher  (1877)  explained  Busch's  experiment,  not  by  an 
angulation  of  the  intestinal  walls  caused  by  different 
amounts  of  pressure,  but  by  the  dilatation  of  the  intestine. 


ACCIDENTS  OF  HERNIA. 


97 


When  he  filled  the  portion  of  the  intestine  above  the  stenosis 
with  water,  he  observed  that  the  apex  of  the  wedge  of 
water  was  at  the  constriction,  and  that  a  certain  amount  of 
pressure  would  force  the  water  through  the  stenosis.  If  a 
glass  cylinder  was  now  introduced  from  above  and  pushed 
down  upon  the  stenosis,  so  that  the  intestine  immediately 
above  the  constriction  was  dilated,  the  escape  of  fluid  was 
suddenly  checked.  Kocher 
explained  this  by  assuming 
that  the  column  of  water, 
together  with  the  movable 
mucous  membrane,  formed 
a  wedge,  and  that  the  es- 
cape of  fluid  was  permitted 
only  when  the  apex  of  the 
wedge  extended  below  the 
stenosis.  He  illustrated  this 
by  the  diagrams  shown  in 
figure  28,  a-c. 

Reichel  (1886),  from  his 
own  investigations,  gives 
another  explanation  for  the 
result  of  this  experiment. 
He  supposes  that  the  stop- 
page is  actually  due  to  the 
fact  that  when  the  intestine 
above  the  constriction  is 
tensely  filled,  the  mucous 
membrane  from  below  is 
drawn  into  the  upper  por- 
tion, and  that  an  invagina- 
tion is  thus  produced.  The 
serosa  is  unable  to  take  part  in  this  displacement,  since  it 
is  more  tightly  held  by  the  constricting  thread. 

Korteweg  (1878)  came  to  a  result  quite  similar  to  that 
of  Reichel.  He  concluded  that  an  intestinal  fold  was 
produced  below  the  thread,  and  that  this  fold  was  drawn 
into  the  upper  portion  of  the  intestine,  completely  closing 
the  stenotic  orifice  (Fig.  29).  " 


Fig.  28  (c).— Injection  under 
very  great  pressure;  as  a  result 
of  the  great  distention  the  apex 
of  the  wedge  is  displaced  upward 
and  no  fluid  escapes. 


98 


HERNIA. 


There  are  two  chief  objections  to  the  interpretations 
given  to  these  experiments  by  their  authors  :  first,  the 
valvular  formation  which  Roser  claimed  to  exist  in  his 
experiment  has  not  been  recognized  ;  and,  second,  Lossen's 
explanation  of  the  compression  of  the  efferent  end  by  the 
afferent  intestine  is  inapplicable,  since  it  has  been  generally 
confirmed  that  there  is  always  a  complete  closure  of  both 
the  efferent  and  the  afferent  ends  of  the 
coil  in  every  case  of  strangulation. 

From  what  has  been  said,  it  may  be 
stated  that  the  following  points  are  those 
which  have  made  the  mechanism  of  the 
so-called  fecal  strangulation  more  intelli- 
gible : 

1.  The  relative  narrowness  of  the  her- 
nial orifice  is  a  predisposing  factor  for  the 
development  of  strangulation.  This  nar- 
rowness may  be  due  to  the  hernial  orifice 
itself,  to  the  neck  of  the  sac  as  a  result 
of  adhesions,  to  omentum  or  mesentery 
which  have  been  simultaneously  wedged  in,  or  to  a  turn- 
ing of  the  intestine  upon  its  longitudinal  axis. 

2.  This  stenosis  within  the  hernial  orifice  is  considerably 
increased  by  the  entrance  of  intestinal  contents  into  the 
herniated  intestinal  coil,  which  is  subjected  partly  to  a 
compression  (Lossen)  and  partly  to  an  angulation  (Busch). 

3.  The  complete  closure  of  both  the  afferent  and  also 
the  efferent  ends  of  the  intestinal  coil  is  effected  by  the 
further  dilatation  of  the  intestine  (Kocher),  as  a  result  of 
which  we  must  assume  the  production  of  a  variety  of 


Fig.  29. 


ACCIDENTS  OF  HERNIA.  09 

invagination  or  valvular  arrangement  of  the  mucous  mem- 
brane (Reichel,  Korteweg). 

The  Symptoms  and  Course  of  Intestinal  Strangula= 
tion. — A  strangulation  of  the  intestine  almost  always 
appears  suddenly,  so  that  the  patient  is  able  to  state  the 
exact  moment  of  its  occurrence  and  its  immediate  cause, 
which  is  usually  a  cough,  the  lifting  of  a  weight,  or  some- 
thing similar.  The  individual  immediately  experiences  a 
stinging  pain  in  the  region  of  the  hernial  orifice,  the  her- 
nia, which  has  either  appeared  for  the  first  time  or  has 
been  previously  reducible,  cannot  be  returned  to  the  ab- 
dominal cavity,  and  to  this  is  added  the  phenomena  which 
we  have  learned  to  know  as  the  ^^  irritative  peritoneal 
symptoms.'^  These  symptoms  in  particular  are  nausea, 
eructation,  and  vomiting,  w^hich  is  reflex  at  first,  but  also 
due  to  the  intestinal  occlusion.  If  the  seat  of  strangula- 
tion is  located  high  up  in  the  intestinal  tract,  all  food  is 
vomited  soon  after  its  ingestion,  and  the  patient  retains 
nothing ;  the  lower  the  obstruction,  the  later  the  appearance 
of  the  vomiting.  As  soon  as  the  stomach  has  been  emptied 
the  dammed-up  intestinal  contents  are  ejected,  the  vomited 
matter  takes  on  a  foul  odor  and  finally  assumes  a  pro- 
nounced fecal  type.  From  the  moment  of  strangulation 
neither  feces  nor  gas  are  passed  by  the  rectum,  although 
particles  of  feces  located  below  the  stenosis  may  be  washed 
out  by  intestinal  irrigation. 

A  further  symptom,  and  one  which  is  equally  important 
in  any  case  of  intestinal  occlusion,  is  the  occurrence  of 
attacks  of  colicky  pain  wdiich  are  due  to  the  intestine 
above  the  seat  of  strangulation  attempting  to  overcome  the 
obstacle  by  increased    peristalsis.     In   lean  patients  the 


100  HERNIA. 

contour  of  the  distended  afferent  intestine  may  be  seen 
through  the  abdominal  wall,  as  may  also  the  peristaltic 
movements  during  the  attacks  of  pain.  The  abdominal 
wall  which  is  still  soft  becomes  tense  and  hard  over  the 
dilated  intestine.  This  increased  resistance  during  the 
attack  may  also  be  felt  in  patients  with  thick  abdominal 
walls  which  obscure  the  individual  contours  of  the  intes- 
tine. 

The  hernial  tumor,  which  in  the  beginning  was  soft  and 
painful  only  upon  considerable  pressure,  becomes  more  and 
more  tense  both  from  the  formation  of  hernial  fluid  and 
also  from  the  edematous  swelling  of  the  hernial  contents 
and  the  accumulation  of  gas.  It  finally  becomes  very 
sensitive  to  the  slightest  touch.  If  the  strangulation  has 
existed  for  some  time,  the  inflammation  within  the  sac 
spreads  to  the  overlying  skin,  which  becomes  edematous 
and  thickened,  so  that  it  can  no  longer  be  lifted  up  in  folds ; 
inflammatory  redness  then  appears,  the  symptoms  grow 
worse,  and  external  perforation  finally  occurs,  the  hernial 
contents  having  meanwhile  become  gangrenous.  In  this 
manner  a  preternatural  anus  or  a  fecal  fistula  is  formed. 
Sometimes  the  previously  described  condition  runs  its 
course  with  very  little  abdominal  involvement.  In  a  large 
number  of  cases,  however,  the  symptoms  are  more  severe ; 
the  purulent  inflammation  produced  by  the  intestinal  gan- 
grene also  extends  to  the  general  peritoneum  and  causes  a 
purulent  peritonitis.  This  last  and  gravest  stage  is  signal- 
ized by  an  immediate  change  in  the  symptomatology.  The 
abdomen  becomes  tympanitic,  tense  to  the  touch,  extremely 
painful,  and  particularly  sensitive  to  pressure,  vomiting 
occurs  with  renewed  violence,  and  the  general  condition 


ACCIDENTS  OF  HERNIA.  101 

becomes  visibly  worse.  The  patient,  who  in  the  begin- 
ning of  the  strangulation  felt  strong  and  experienced 
nothing  but  a  sense  of  anxiety  from  the  increasing  pain 
and  the  obstruction  to  the  passage  of  the  feces,  collapses 
at  the  moment  in  which  the  purulent  inflammation  extends 
to  the  peritoneum.  Marked  shock  causes  the  pulse  to 
become  small,  easily  compressible,  often  scarcely  percepti- 
ble, and  increased  in  frequency  to  from  120  to  160  beats 
to  the  minute.  The  eyes  sink  back  in  the  orbits,  the  nose 
becomes  pointed,  and  the  entire  body  is  covered  with  a 
cold  sweat.  The  breathing  becomes  superficial  and  acceler- 
ated, partly  from  the  high  position  of  the  diaphragm 
caused  by  the  meteorism  and  partly  from  cardiac  weakness. 
The  action  of  toxic  substances  upon  the  kidneys,  the  fall 
of  blood  pressure,  and  the  deficient  absorptive  power  of 
the  paralyzed  intestine  cause  a  gradual  diminution  of  the 
urinary  secretion,  and  may  produce  complete  anuria. ^  In 
this  stage  unconsciousness  mercifully  supervenes  and  spares 
the  patient  from  the  terrors  of  impending  death.  According 
to  Graser,  about  95  ^  of  the  untreated  cases  of  strangu- 
lated intestinal  hernia  end  in  death. 

The  symptomatology  of  the  strangulation  of  a  hernia  of 
the  intestinal  wall  (see  page  36)  is  in  marked  contrast  to 
that  of  the  strangulation  of  an  entire  loop.  There  is  a  great 
probability,  for  various  reasons,  that  the  severity  of  the 
existing  aifection  will   not  be  appreciated.     In  the  first 

^  The  demonstration  of  indican  in  the  urine  is  not  an  absolute  sign 
of  intestinal  occlusion,  and  may  not  infrequently  be  accomplished  in 
cases  of  pure  peritonitis.  According  to  Jaffe,  the  indican  is  formed 
by  the  absorption  of  the  decomposition  product  of  the  intestinal  con- 
tents, iudol,  and  its  elimination  in  the  urine  as  indoxyl-potassium  sul- 
phate. 


102  HERNIA. 

PLATE  1. 

a,  A  Strangulated  Hernia  of  the  Intestinal  Wall. — An  early 
stage  of  a  strangulation  which  involves  a  portion  of  the  intestine  oppo- 
site to  the  insertion  of  the  mesentery.  The  strangulated  portion,  and 
particularly  the  constriction-rings,  are  intensely  reddened,  but  there 
are  no  profound  disturbances  of  the  nutrition  of  the  intestinal  wall. 

b,  A  Strangulated  Coil  of  Intestine  in  Which  More  Marked 
Circulatory  Disturbances  are  Observed. — The  coil  is  dark  blue, 
but  its  peritoneum  still  retains  its  moist  glistening  surface.  The  con- 
striction-rings are  distinctly  marked  without  being  gangrenous. 

c,  A  Strangulated  Coil  of  Intestine  after  the  Strangulation 
Existed  for  a  Considerable  Period  of  Time. — The  color  has  be- 
come almost  black  and  the  peritoneal  surface  is  dull  and  covered  with 
flakes  of  fibrin.  The  constriction-rings  are  deeply  sunken,  their  walls 
markedly  thinned,  relaxed,  and  dirty  gray  in  color.  Both  constric- 
tion-rings are  gangrenous  and  hemorrhages  are  observed  in  the  mesen- 
tery. 

place,  the  hernias  are  very  small  and  consequently  may 
easily  be  overlooked,  and,  secondly,  the  intestinal  occlu- 
sion is  incomplete,  since  only  a  portion  of  the  intestinal 
wall,  usually  that  opposite  the  mesentery,  is  involved,  and 
although  intestinal  strangulation  is  present,  flatus  and  liquid 
stools  may  still  be  passed.  The  sudden  appearance  of 
pain  and  the  occurrence  of  nausea  and  vomiting,  however, 
are  observed  in  strangulated  hernias  of  the  intestinal  wall, 
as  are  also  the  subsequent  inflammatory  phenomena,  which 
may  cause  either  external  or  internal  perforation  and  the 
consequent  formation  of  a  fecal  fistula  or  of  a  septic  peri- 
tonitis. 

In  every  intestinal  strangulation,  the  tighter  the  con- 
striction, the  more  rapid  the  entire  course  of  the  afl\?ction 
and  the  more  severe  the  general  symptoms  from  the  begin- 
ning.    The  sudden  occurrence  of  collapse  or  severe  shock 


Tab.  I 


%■ 


^'W-  /; 


^^9 


Lith.  Anst  t'.  Rpidihtild,  Munchen . 


ACCIDENTS  OF  HERNIA.  103 

is  sometimes  a  better  indication  of  the  severity  of  the 
strangidation,  and  consequently  of  the  danger  of  a  perma- 
nent disturbance  of  the  nutrition  of  the  gut,  than  the  direct 
inspection  of  the  exposed  intestinal  coil.  Plate  1  shows 
the  appearance  of  the  intestine  in  different  stages  of 
strangulation. 

Strangulation  of  Omentum. — The  only  form  of  stran- 
gulation of  the  omentum  is  necessarily  the  one  known  as 
elastic  strangulation.  The  circulatory  disturbances  pro- 
duced in  this  manner  gradually  cause  a  serous  infiltration 
and  hemorrhagic  infarction  of  the  constricted  portion  of 
omentum.  In  the  further  course  of  the  affection,  throm- 
bosis occurs  in  the  vessels  and  the  entire  mass  of  strangu- 
lated omentum  finally  becomes  gangrenous.  A  large 
quantity  of  hernial  fluid  is  usually  produced,  and  if  the 
strangulation  lasts  a  sufficient  length  of  time,  migrating 
bacteria  may  infect  this  fluid  and  cause  it  to  suppurate 
just  as  in  an  intestinal  strangulation. 

The  clinical  symptoms  of  a  beginning  omental  strangu- 
lation are  very  similar  to  those  of  the  early  stage  of  stran- 
gulation of  the  intestine.  The  strangulation  commences 
with  a  sudden  stinging  pain,  and  this  is  ordinarily  soon 
followed  by  nausea  and  vomiting,  which  are  purely  reflex. 
The  symptoms  may  now  abate  somewhat,  vomiting  ceases, 
flatus  and  sometimes  feces  are  passed,  but  the  patient  always 
continues  to  experience  a  sensation  of  illness,  since  the  her- 
nial tumor  cannot  be  made  smaller  by  taxis  and  becomes 
more  and  more  tender  and  tense  from  the  inflammation 
and  increased  amount  of  hernial  fluid.  If  surgical  aid  is 
not  given  in  this  stage,  the  inflammation  spreads  to  the 
surrounding  tissues,  and  one  of  two  things  may  occur : 


104 


HERNIA. 


Fm.  30. 


ACCIDENTS  OF  HERNIA.  lOo 

Fig.  30. — Retrograde  strangulation  :  I,  Retrograde  strangulation 
of  an  intestinal  coil  (Schniidt).  At  the  autopsy  upon  a  woman  who 
died  from  a  strangulated  umbilical  hernia,  the  intestinal  coils  within 
the  hernial  siic  Avere  found  to  ho  unchanged  and  non-strangulated,  but 
there  was  an  intestinal  loop,  with  all  the  signs  of  stiangulatiou,  whicli 
extended  from  the  hernial  sac  into  the  abdominal  cavity.  The  dis- 
tended afferent  and  the  collapsed  efferent  intestine  maybe  seen  within 
the  hernial  sac  ;  the  strangulated  intestinal  loop,  which  has  been  shaded 
darker  in  the  illustration,  protrudes  from  the  sac  into  the  abdominal 
cavity.  II,  Retrograde  strangulation  of  a  vermiform  apjDendix  ( ^laydl ) . 
The  proximal  portion  of  the  apijendix  had  remained  in  the  hernial  sac 
unchanged,  but  the  peripheral  portion,  more  darkly  shaded  in  the  figure, 
projected  into  the  abdominal  cavity  and  exhibited  distinct  signs  of 
strangulation.  At  a  a'  is  shown  the  seat  of  constriction.  Ill,  Retro- 
grade strangulation  of  a  Fallopian  tube  (Maj'dl).  The  larger  portion 
of  the  tube  was  found  unchanged  in  the  hernial  sac  ;  the  smaller  por- 
tion, strangulated  at  a  «'',  extended  into  the  aMominal  cavity.  IV, 
Retrograde  strangulation  of  a  subserous  intestinal  tumor  (iMaydl). 
The  pedicle  of  the  tumor  has  become  compressed  in  consequence  of  the 
descent  of  the  bowel. 


the  pus  may  perforate  externally^  In  which  fortunate  case 
the  necrotic  piece  of  omentum  is  cast  off  and  spontaneous 
cure  results,  or  the  inflammation  may  extend  to  the  ab- 
dominal cavity  and  produce  a  septic  peritonitis.  Although 
it  may  be  said  in  a  general  way  that  omental  strangulation 
has  a  less  stormy  inception  and  a  slower  course  than  intes- 
tinal strangulation,  there  are  nevertheless  cases  of  pure 
omental  strangulation  wdiich  begin  with  just  as  severe 
symptoms -as  does  a  strangulation  of  the  gut,  and  which 
make  the  diagnosis  very  difficult  and  sometimes  quite  im- 
possible. [I  have  operated  upon  cases  with  typical  acute 
omental  strangulation  with  severe  symptoms  simulating 
intestinal  strangulation. — Ed.] 

Mention  should  also  be  made  of  a  variety  of  strangula- 


106  HERNIA. 

tion,  several  examples  of  which  have  recently  been  fur- 
nished by  Maydl,  and  to  which  he  gives  the  name  of 
retrograde  strangulation  (Fig.  30).  In  this  form  the 
strangulated  portion  of  the  viscus  is  not  situated  within 
the  hernial  sac,  but  within  the  abdominal  cavity.  If  the 
omental  hernia  illustrated  in  figure  14  (page  40)  had 
ever  become  strangulated,  it  would  have  been  a  strangu- 
lation of  this  type.  In  addition  to  omentum,  this  form  of 
strangulation  has  been  observed  to  involve  an  intestinal 
coil  by  B.  Schmidt ;  and  an  appendix,  a  Fallopian  tube, 
and  a  pedunculated  intestinal  tube  by  Maydl. 

It  is  impossible  to  definitely  state  the  period  of  time 
within  which  a  strangulation  usually  runs  its  course.  If 
the  constriction  is  not  very  tight,  there  may  be  no  marked 
disturbances  of  the  nutrition  of  the  intestine  even  after 
several  days,  while  in  other  instances,  in  which  the  stran- 
gulation is  more  severe,  gangrene  may  make  its  appearance 
within  a  few  hours.  The  severity  of  the  case  is  conse- 
quently better  determined  by  a  careful  study  of  the  gen- 
eral symptoms,  and  of  the  local  signs  exhibited  by  the 
hernial  tumor,  than  by  the  time  that  has  elapsed  since 
the  commencement  of  the  strangulation. 

The  most  frequent  error  in  the  diagnosis  of  strangula- 
tion is  Its  confusion  with  an  inflamed  hernia.  If  the 
slightest  doubt  exists,  the  case  should  be  treated  as  one  of 
strangulation.  If  this  course  is  pursued  and  every  sus- 
pected case  of  strangulated  hernia  is  operated  upon,  it  may 
occasionally  happen  that  the  operation  reveals  an  error  of 
diagnosis,  but  scarcely  any  damage  has  been  done  the 
patient ;  while  if  the  strangulation  is  unrecognized  and  the 
necessary  procedures  are  neglected,  the  error  may  be  most 
fatal  in  its  consequences. 


ACCIDENTS  OF  HERNIA.  107 

The  Treatment  of  Strangulated  Hernia. — If  called  to 
a  case  of  strangulated  hernia  in  the  daytime,  the  sun 
should  not  be  allowed  to  set,  if  called  in  the  night,  the  sun 
should  not  be  allowed  to  rise,  before  the  strangulation  has 
been  relieved.  This  advice  of  Stromeyer,  which  even  at 
the  present  day  is  not  sufficiently  heeded,  is  worthy  to  be 
taken  to  heart.  It  should  be  given  all  the  more  emphasis, 
since  the  means  which  we  possess  for  the  relief  of  the  stran- 
gulation can  be  designated  as  harmless  and  safe  in  compari- 
son with  the  great  dangers  which  are  coincident  with  an 
untreated  case  of  strangulated  hernia.  There  are  two 
methods  of  reduction  to  be  described,  the  non-operative, 
which  is  known  as  taxis,  and  the  operative,  which  is 
known  as  herniotomy. 

Taxis, — Taxis  is  indicated  in  all  cases  of  strangulated 
hernia  in  which  there  is  no  impairment  of  the  vitalit}^  of 
the  strangulated  viscera  and  in  which  there  is  an  absence 
of  any  inflammation  which  might  infect  the  peritoneal 
cavity.  If  there  is  any  doubt  whatever  as  to  the  presence 
of  either  of  these  contraindications,  it  will  be  well  to  dis- 
regard taxis  altogether  and  to  proceed  to  herniotomy. 

Taxis  is  performed  by  firmly  grasping  and  compressing 
the  region  of  the  neck  of  the  hernial  sac  with  the  left  hand 
and  then  exerting  a  uniform  and  constant  pressure  upon 
the  entire  hernial  tumor  with  the  right  hand,  taking  care 
not  to  press  the  hernia  toward,  but  rather  to  draw  it  away 
from,  the  abdomen  (Fig.  31).  In  this  manner  the  pro- 
duction of  an  angulation  of  the  intestine  at  the  hernial 
orifice  is  best  avoided  and  some  of  the  contents  of  the 
strangulated  intestine  may  frequently  be  pushed  through 
the  constricting  ring.     If  this  can  be  accomplished,  a  great 


108 


HERNIA. 


Fig.  31. — The  method  of  performing  taxis. 


ACCIDENTS  OF  HERNIA.  109 

deal  has  already  been  gained,  since  the  tension  of  the  intes- 
tinal coil  immediately  decreases  and  reduction  may  fre- 
quently be  effected  by  a  single  effort.  Success  may  some- 
times be  attained  by  drawing  the  hernial  tumor  to  one  side 
or  the  other,  in  order  to  overcome  any  angulation  of  the 
strangulated  intestine,  such  as  that  observed  in  Busch's 
experiment.  If  the  attempt  to  reduce  a  portion  of  the 
intestinal  contents  is  successful,  a  gurgling  murmur  is 
usually  heard.  The  most  important  part  of  the  procedure 
of  taxis  is  the  compression  of  the  neck  of  the  hernial  sac, 
since  if  this  is  neglected  and  pressure  is  simply  made  upon 
the  convexity  of  the  hernia,  the  same  conditions  will  exist 
which  we  have  studied  in  Roser's  experiment  (Fig.  23), 
and  even  great  force  will  fail  to  press  a  bubble  of  air  or 
a  drop  of  fluid  out  of  the  strangulated  intestinal  coil. 

Care  must  be  taken  that  too  much  force  is  not  employed, 
since  excessive  kneading  and  pressing  of  the  hernial  tumor 
may  easily  produce  hemorrhages  in  the  walls  of  the  stran- 
gulated viscus  and  increase  the  nutritional  disturbances 
which  are  already  present.  Disregarding  the  danger  of 
reduction  en  masse  (see  page  114),  such  forced  taxis  may 
cause  a  much  more  severe  injury  and  produce  a  perfora- 
tion of  the  strangulated  intestinal  coil.  At  first  glance 
the  taxis  seems  to  have  been  successful,  the  hernial  tumor 
suddenly  becomes  soft  and  may  be  easily  and  completely 
reduced.  The  true  condition  of  affairs  is  revealed  only 
too  soon,  however,  by  the  sudden  collapse  of  the  patient 
and  by  the  rapid  appearance  of  the  symptoms  of  a  perfo- 
rative peritonitis.  In  such  a  case,  further  surgical  aid, 
Avhich  can  be  nothing  but  immediate  laparotomy,  w411 
almost  always  be  too  late  to  save  the  patient. 


110  HERNIA. 

A  correctly  performed  taxis  may  be  aided  by  the  employ- 
ment of  certain  auxiliary  measures.  The  simplest  of  these 
is  to  obtain  a  relaxation  of  the  abdominal  Avail  and  a  diminu- 
tion of  the  intra-abdominal  pressure  by  having  the  patient 
open  his  mouth,  breathe  deeply,  and  flex  the  lower  extrem- 
ities at  the  hip  and  knee.  Another  measure,  which  is  not 
without  influence  in  certain  forms  of  strangulation,  is  the 
effect  of  cold.  This  may  be  produced  by  the  application 
of  an  ice-bag,  or,  better  still,  by  dropping  or  spraying 
ether  upon  the  hernial  tumor.  Whether  the  effect  pro- 
duced is  due  to  the  narrowing  of  the  blood-vessels,  to  the 
contraction  of  the  muscular  coat  of  the  intestine,  or  to 
other  factors  is  still  an  open  question.  [Frequent  appli- 
cation of  very  hot  cloths  is  often  of  more  avail  than  the 
ice-bag. — Ed.] 

The  most  effective  auxiliary  measure,  however,  is  the 
production  of  general  anesthesia  by  either  chloroform  or 
ether.  With  the  cessation  of  pain,  the  tension  of  the 
abdominal  wall  is  decreased,  the  entire  musculature  is 
relaxed,  and  reduction  is  frequently  easily  accomplished. 
However,  only  that  physician  should  employ  anesthesia  in 
his  attempted  taxis  who,  in  the  event  of  failure,  is  also  in 
the  position  to  immediately  proceed  to  herniotomy  under 
the  same  anesthesia,  the  consent  of  the  patient  having  pre- 
viously been  obtained.  If  such  a  course  is  not  pursued,  a 
second  anesthesia  would  be  necessary  soon  after  the  first, 
and  this  alone  is  a  great  danger,  particularly  for  indi- 
viduals whose  circulatory  or  respiratory  organs  are  not 
perfectly  healthy.  If  for  any  reason  whatever  the  physi- 
cian cannot  perform  herniotomy,  his  wisest  course  is  to 
leave  the  taxis  to  be  performed  under  an  anesthetic  by  the 
surgeon  of  the  nearest  hospital. 


ACCIDENTS  OF  HERNIA.  1  1 1 

The  aclministration  of  purgatives  by  tlie  mouth  must  be 
regarded  as  absohitely  iuadmissible.  The  employment  of 
enemata,  on  the  contrary,  can  meet  with  no  objection, 
although  the  relief  afforded  by  emptying  the  intestine 
below  the  stenosis  is  usually  but  temporary  in  its  charac- 
ter. Lavage  has  a  very  agreeable  subjective  effect  and 
gives  considerable  relief,  since  it  removes  the  dammed-up 
gastro-intestinal  contents  and  consequently  diminishes  the 
tendency  to  vomiting.  This  favorable  influence  is  not 
only  a  subjective  one,  but  the  cessation  of  vomiting  is  of 
great  importance  to  the  patient,  particularly  in  reference 
to  the  production  of  anesthesia,  since  the  danger  of  an 
aspiration  pneumonia  is  greatly  lessened. 

The  administration  of  morphin  or  opium  is  sometimes 
indicated,  since  it  relieves  pain  and  therefore  lessens  the 
tension  of  the  abdominal  wall  and  the  consequent  resist- 
ance to  the  attempts  at  reduction. 

Taxis  should  never  be  employed  for  too  long  a  time,  and 
the  extreme  limit  should  be  placed  at  a  half-hour.  [Per- 
sonally I  would  limit  taxis  to  five  minutes.  I  have  seen  a 
fatal  result  from  taxis  of  but  little  more  than  five  minutes^ 
duration. — Ed.] 

Batsch  has  recently  claimed  that  cases  of  intestinal 
occlusion  from  the  most  varied  causes  can  be  favorably 
influenced  by  large  subcutaneous  doses  of  atropin,  and  this 
therapy  has  been  extended,  by  himself  and  certain  other 
physicians,  to  the  treatment  of  strangulated  hernia.  All 
our  previous  experience  contradicts  the  existence  of  such  an 
influence  so  strongly  that  we  must  regard  medicinal  reme- 
dies as  absolutely  contraindicated  by  the  presence  of  a 
strangulated  hernia. 


112  HERNIA. 

Too  mucli  emphasis  cannot  he  placed  upon  the  warning 
against  such  attempts  at  reduction,  extending  sometimes 
over  several  days,  and  the  consequent  neglect  of  the  most 
favorable  time  for  the  operation  for  strangulated  hernia. 

A  further  series  of  auxiliary  procedures  will  be  briefly 
mentioned,  which,  although  no  longer  employed,  are  of 
considerable  historic  interest. 

The  employment  of  cold  water  is  thus  described  by 
Kirby :  '^  I  took  the  patient  out  of  bed,  laid  him  naked  upon 
the  wooden  floor,  and  threw  pail  after  pail  of  cold  water 
upon  the  hernial  tumor  and  abdomen.  This  procedure 
was  continued  until  the  respiration  became  labored  and 
until  the  patient  was  very  much  exhausted." 

A  hot  general  bath  at  a  temperature  of  99.5°  to  108.5° 
F.  was  very  popular;  "this  is  most  effective  when  it  brings 
about  a  weakness  bordering  upon  unconsciousness.  During 
the  collapse  which  is  thus  produced  the  pressure  upon  the 
hernial  tumor  must  be  renewed  and  maintained  as  long 
as  the  condition  of  the  patient  will  permit"  (Kirby). 

In  the  same  category  belongs  the  performance  of  vene- 
section. "The  sooner  it  is  employed,  the  better  and  more 
helpful  is  the  remedy.  We  bleed  until  the  patient  is 
weakened,  since  we  wish  to  produce  a  marked  impression 
and  the  approach  of  delirium  shows  us  that  this  end  has  been 
attained"  (Kirby). 

Hoping  to  overcome  the  fecal  stasis,  powerful  purgatives 
were  employed,  and  they  were  supposed  to  be  particularly 
indicated  if  the  lumen  of  the  intestine  was  not  completely 
occluded.  It  was  believed  that  the  increased  peristalsis 
would  be  sufficient  to  free  the  strangulated  intestine. 

For  some  time  tobacco  was  supposed  to  exert  quite  a 
special  influence,  and  it  was  employed  as  an  infusion,  which 
was  thrown  into  the  rectum,  and  also  in  the  form  of  tobacco  • 
smoke,  which  was  blown  through  the  anus  into  the  intestine. 

Patients  were  frequently  placed  in  most  peculiar  posi- 
tions. For  example,  it  was  recommended  that  the  physi- 
cian should  place  the  legs  of  the  patient  over  his  shoulders 
and  attempt  to  reduce  the  hernia  by  repeated  shakings  of 


A CCIDENTS  OF  HERNIA .  113 

the  entire  body.  A  similar  procedure,  the  so-called  ''travel- 
ing method,"  was  sul^jected  to  the  most  drastic  censure  by 
Dieffenbach.  "This  method  consisted  in  placing  the  head 
and  back  of  the  patient  upon  a  wheelbarrow,  the  thighs 
being  elevated  upon  the  front  and  higher  portion,  so  that 
the  knees  were  flexed  and  the  legs  hung  down.  While  the 
unfortunate  patient  was  trundled  over  a  rough  pavement, 
the  operator  ran  backward  in  front  of  the  wheelbarrow  and 
manipulated  the  hernia,  in  the  hope  that  the  taxis,  com- 
bined with  the  shaking  of  the  patient,  would  be  successful 
in  effecting  reduction." 

In  conclusion,  mention  should  be  made  of  puncture  of 
the  hernial  tumor,  which  was  recommended  particularly 
b}'  French  authors.  It  was  supposed  that  the  intestinal 
contents  could  be  aspirated  with  a  fine  needle  and  that 
the  relaxed  intestine  could  then  be  more  easily  returned 
into  the  abdominal  cavity. 

If  the  taxis  is  successful,  and  if  the  surgeon,  by  intro- 
ducing his  finger  into  the  hernial  orifice,  has  convinced 
himself  that  it  is  empt}^,  a  pad  of  gauze  should  be  placed 
over  the  hernial  orifice  and  held  in  this  position  by  means 
of  a  bandage  in  order  to  prevent  the  descent  of  the  gut 
and  the  consequent  renewal  of  the  strangulation.  If  the 
hernial  region  has  not  been  contused  by  the  taxis,  a  truss 
may  be  immediately  applied.  The  condition  of  the  patient 
rapidly  improves.  He  feels  well,  nausea  and  vomiting 
immediately  disappear,  after  several  hours  flatus  is  usually 
passed,  and,  with  the  exception  of  the  pain  produced  by 
the  taxis,  the  tenderness  of  the  hernial  region  becomes 
markedly  lessened.  The  bowels  are  not  usually  evacuated 
until  twenty-four  to  thirty-six  hours  have  elapsed,  and  it 
is  well  to  save  the  intestine  and  avoid  very  active  peris- 
talsis by  omitting  purgatives  during  the  first  day  after  the 
taxis.     At  the  expiration  of  this  time,  the  rectal   injec- 


114  HERNIA. 

Fig.  32. — Apparent  reduction  of  an  intestinal  coil  (diagrammatic): 
a,  The  entire  hernial  sac  Avith  its  contents  has  been  pushed  into  the 
abdomen  ;  b,  the  peripheral  portion  of  the  hernial  sac  lies  externall}', 
while  the  central  portion  and  the  contained  intestine,  together  Avith 
the  constricting  ring,  have  been  pushed  into  the  abdomen.  In  both 
instances  the  seat  of  the  constriction  is  in  the  neck  of  the  sac  and  is 
represented  by  a  dotted  red  line.  In  these  cases  the  reduction  en  masse 
is  in  inguinal  hernia,  but  it  occurs  in  a  similar  manner,  although  not 
so  frequently,  in  the  other  varieties. 

tion  of   10    c.c.    of  glycerin    will    usually  furnish    good 
results. 

Even  after  an  apparently  successful  taxis  the  patient 
should  be  kept  under  medical  observation  for  several  days, 
since  the  signs  of  strangulation  sometimes  still  persist. 
Such  an  occurrence  may  be  due  to  the  fact  that  the  hernial 
viscus  has  been  replaced  but  that  a  volvulus  still  remains, 
to  an  angulation  of  the  intestine  caused  by  adhesions,  to 
inflammatory  changes  in  the  gut  which  end  in  gangrene 
with  consequent  peritonitis  and  intestinal  paralysis,  or, 
finally,  to  the  fact  that  the  hernial  tumor  together  with  the 
ring  of  constriction  has  simply  been  displaced  by  an  appar- 
ently successful  taxis.  This  latter  occurrence  is  known  as 
apparent  reduction,  reduction  en  masse,  or  reduction  en  bloc 
(Fig.  32).  The  amount  of  force  which  has  been  employed 
in  such  an  apparent  reduction  need  not  necessarily  be  very 
great,  and  occasionally  it  has  even  been  observed  in  cases 
where  the  patient  has  reduced  the  strangulated  hernia  him- 
self. In  such  cases  the  entire  hernial  tumor  is  either  only 
pushed  to  one  side  and  forced  between  the  individual  layers 
of  the  abdominal  wall,  or  the  hernia,  together  with  its  sac, 
is  pushed  toward  the  abdomen,  in  which  instance  the  adja- 
cent parietal  peritoneum  is  stripped  up  from  the  abdominal 


Fig.  32. 


A  CCI DENTS  OF  HERNIA .  115 

wall.  Sometimes  only  the  proximal  portion  of  the  sac  is 
displaced  in  die  manner  indicated,  while  the  peripheral 
portion  still  remains  ontside.  Isolated  cases  of  this  variety 
of  apparent  reduction  have  been  described  in  which  the  sac 
has  been  lacerated,  in  one  instance  the  sac  having  been 
completely  torn  off  at  the  neck. 

In  addition  to  the  persistence  of  the  symptoms  of  stran- 
gulation, reduction  en  masse  may  sometimes  be  recognized 
by  the  presence  of  a  palpable  tumor  within  the  abdomen 
in  the  neighborhood  of  the  hernial  orifice  or  of  a  round 
circumscribed  swelling  in  the  deeper  portion  of  the  hernial 
canal. 

The  only  possible  treatment  of  any  of  these  disagreeable 
accidents  which  may  occur  after  an  apparently  successful 
taxis  is  in  the  earliest  possible  operation,  which  must  over- 
come the  existing  obstruction  or  remove  from  the  perito- 
neal cavity  those  portions  which  may  have  become  gan- 
grenous. In  a  case  of  reduction  en  masse  an  attempt  may 
be  made  to  force  the  entire  hernial  tumor  down  again ; 
although  a  second  and  more  cautious  attempt  at  taxis 
promises  but  little  chance  of  success,  the  conditions  for  the 
performance  of  the  operation  are  at  least  more  favorable, 
since  a  large  incision  into  the  abdominal  cavity  may  be 
avoided.  If  the  abdominal  cavity  must  be  opened,  the 
coil  which  has  been  reduced  en  masse  will  always  be  found 
in  close  apposition  to  the  inner  side  of  the  hernial  orifice ; 
the  incision  should  consequently  be  made  in  the  hernial 
region  and  continued  toward  the  abdomen  if  necessar}^ 

Herniotcnny . — The  operation  is  indicated  in  all  cases  in 
which  taxis  has  failed  or  in  which  some  contraindication 
to  taxis  exists. 


116  HERNIA. 

The  sooner  the  herniotomy  is  performed,  the  more  favor- 
able is  the  prognosis,  and  it  is  easy  to  furnish  statistic 
proof  that  the  outlook  becomes  more  gloomy  with  every 
day,  or  we  might  even  say  with  every  hour,  during  which 
the  strangulation  is  allowed  to  persist. 

According  to  the  calculation  of  Henggeler,  based  upon 
276  herniotomies,  the  mortality  of  the  cases  operated  upon 
during  the  first  day  after  the  strangulation  is  8.09^; 
during  the  second  day,  22.2^;  during  the  third  day, 
45.5%;  during  the  fourth  day,  60.0%. 

Published  statistics  in  reference  to  the  total  mortality 
after  herniotomy,  like  those  in  reference  to  the  radical 
operation,  have  an  authoritative  significance  only  when 
they  are  based  upon  the  entire  material  of  one  and  the 
same  hospital  for  a  lengthy  period  of  time  or  upon  the 
work  of  one  and  the  same  operator.  In  addition  to  this, 
it  must  be  remembered  that,  owing  to  the  perfection  of  the 
entire  domain  of  abdominal  surgery,  in  latter  years,  con- 
ditions have  considerably  improved,  particularly  in  the 
treatment  of  gangrene  and  suspected  gangrene  of  the 
intestine.  Without  a  special  consideration  of  the  results 
obtained  in  the  cases  with  intestinal  gangrene  and  how 
these  results  vary  with  the  treatment, — i.  e.,  whether  an 
artificial  anus  or  a  resection  is  made, — the  following  table 
will  furnish  an  idea  of  the  mortality  of  herniotomy  in 
general.  It  is  based  upon  some  statistics  published 
recently  which  conform  to  the  previously  stated  stipula- 
tions, upon  the  herniotomies  performed  in  the  Gottingen 
Clinic  from  1884  to  1900  inclusive,  and  upon  all  the 
herniotomies  performed  in  various  clinics,  from   1884  to 


ACCIDENTS  OF  HERNIA. 


117 


1900   inclusive,   under  the  direction  of  Professor  Braun 
(according  to  the  works  of  Borchard  and  Wege) : 


Herniot- 

Number 
of  Cases 

WITH 

Number 
of     Cases 

Name  of  Au- 

omies 

Mor- 

WITH Gan- 

Mor- 

Total 

Mor- 

thor (Opera- 

Per- 

NON-GAN- 

tality 

grene   OR 

tality 

Num- 

tality 

formed 

IN  Per 

Suspected 

IN  Per 

IN  Per 

tor). 

IN  the 

GRICNOrS 

Con- 

Cent. 

Gangrene 

Cent. 

ber. 

Cent. 

Years  : 

OF      the 

tents, 

Contents. 

Habs     (Hage- 

dorn)  .... 

1883-1891 

130 

14.6  5i 

40 

40.05^ 

170 

17.0  5i 

Henggeler* 

(Kronlein)    . 

1881-1894 

206 

9.7  5^ 

48 

85.4^ 

254 

24.0  5i 

GottingerKlin- 

ik  (Kon  i  g  , 

Braun)    .   .    . 

1884-1900 

152 

13.1  i 

49 

71.4^ 

201 

27.3  5i 

Braun      .... 

1884-1900 

129 

8.5  5^ 

38 

57.8  5i 

167 

19.0  f* 

Petersen 

(Czernv)    .   . 

1877-1900 

216 

11.0  fc 

52 

SO.Oji 

280 

18.5 ''s 

Maydl     :  .    .    . 

1891-1896 

293 

17.75* 

Hofnieister 

(v.  Bruns)     . 

1896-1900 

39 

10.2  f^ 

25 

40.0^ 

64 

21.9  5i 

If  these  cases  are  added  together^  we  obtain  a  total  of 
1429  herniotomies  with  296  deaths,  which  gives  a  total 
mortality  of  20.7^. 

The  preparation  of  the  patient  for  a  herinotomy  does 
not  diflPer  from  that  for  any  other  aseptic  operation.  The 
condition  of  the  patient  permitting,  he  is  given  a  bath,  and 
in  all  cases  the  hernial  region  and  its  surroundings  are 
shaved  and  carefully  disinfected  in  the  usual  way.  The 
anesthetic  must  be  given  with  great  care,  particularly  to 
patients  in  a  condition  of  shock  and  to  those  very  stout 
elderly  individuals  who  already  suffer  from  impairments 
of  the  respiratory  and  circulatory  systems.  In  such  cases 
it  is  better  to  avoid  general  anesthesia  and  employ  the 
infiltration  anesthesia  of  Schleich,   which   is   particularly 

^  Computed  by  omitting  the  non-operative  cases  from  Henggeler's 
tables. 


118  HERNIA. 

applicable  in  this  operation  on  account  of  the  insensibility 
of  the  surface  of  the  intestine. 

The  first  step  in  the  operation  of  herniotomy  is  the 
exposure  and  opening  of  the  hernial  sac.  The  cutaneous 
incision  is  carried  above  the  neck  of  the  sac  for  3  to  5  cm. 
so  that  the  seat  of  the  constriction  may  be  freely  inspected. 
The  tissues  at  some  distance  peripheral  to  the  constriction 
are  then  picked  up  with  two  pairs  of  rat-toothed  forceps 
and  the  hernial  coverings  carefully  divided  between  them 
until  the  sac  has  been  opened.  The  greatest  care  is  neces- 
sary in  this  step  of  the  operation,  because  if  the  hernial 
fluid  is  small  in  amount  or  absent,  an  intestinal  loop  lying 
directly  against  the  hernial  sac  could  easily  be  incised. 
Hernial  fluid  is  usually  present,  however,  and  its  escape  is 
the  best  indication  that  the  sac  has  been  opened  in  some 
part  of  the  wound.  From  this  opening  the  incision  in  the 
hernial  sac  is  enlarged,  either  with  scissors,  or  more  safely 
upon  a  grooved  director.  The  condition  of  the  strangu- 
lated viscera  can  frequently  be  told  from  the  character  of 
the  escaping  hernial  fluid.  If  it  is  clear,  translucent,  and 
odorless,  the  strangulated  portions  are  almost  always  in  a 
good  state  of  nutrition,  and  even  if  the  hernial  fluid  has  a 
slightly  bloody  tinge  and  a  rather  stale  odor,  marked  dis- 
turbances of  nutrition  are  not  always  present.  On  the 
contrary,  if  the  hernial  fluid  is  cloudy  or  purulent  and  has 
a  foul  or  fecal  odor,  most  profound  changes  are  almost 
always  present  in  the  hernial  contents. 

After  the  hernial  fluid  has  escaped,  the  hernial  contents 
are  inspected,  and  the  constricting  ring  is  then  to  be  imme- 
diately divided.  As  we  have  already  seen,  the  constric- 
tion may  be  in  the  neck  of  the  sac  alone  or  in  the  sur- 


ACCIDENTS  OF  HERNIA. 


119 


rounding  tissues,  and  this  is  why  one  case  requires  only 
the  division  of  the  sac,  while  in  another  success  will  not 
be  attained  until  all  the  tissues  of  the  hernial  orifice  have 
been  divided.  The  constriction  may  be  divided  either 
from  without  inward  or  from  within  outward.     The  first 


Fig.  33. — The  division  of  the  constriction  from  without  inward. 


of  these  methods  is  to  be  preferred,  since  the  field  of  oper- 
ation is  freely  exposed  and  any  injured  blood-vessel  may 
be  immediately  caught  and  ligated.  The  ring  of  constric- 
tion is  divided  layer  by  layer  between  two  pairs  of  rat- 
toothed  forceps,  as  is  shown  in  figure  33,  until  the  stran- 


120 


HERNIA. 


gulated  viscus  can  be  easily  drawn  forward  and  it  is  certain 

that  the  constriction  has  been  relieved. 

If  the  constriction  is  divided 
from  within  outward, — and  this  is 
done  particularly  when  the  surgeon 
is  forced  to  operate  without  suffi- 
cient assistance, — a  special  knife  is 
employed,  the  so-called  hernia  knife 
or  herniotome.  The  anterior  and 
posterior  portions  of  the  blade  are 
dull  and  the  intermediate  cutting- 
edge  is  about  IJ  cm.  in  length.  It 
is  purely  a  matter  of  taste  whether 
a  straight  (Fig.  34,  a)  or  a  curved 
herniotome  (Cooper's,  Fig.  34,  b)  is 
employed.  As  shown  in  figure  35, 
the  index- finger  of  the  left  hand  is 
introduced  into  the  hernial  sac  and 
carried  up  to  the  seat  of  the  con- 
striction, and  then  the  hernia  knife 
is  pushed  in  upon  the  finger  which 
guards  the  herniated  intestine  from 
injury.  When  the  cutting-edge  of 
the  hernia  knife  is  within  the  con- 
striction, the  incision  is  made  in  an 
upward  direction  for  from  one  to 
two  millimeters.  If  the  hernial 
contents  cannot  now  be  easily  drawn 

Uij     \i  forward,  notches  of  a  similar  depth 

4^3         '^^y   b^  made  in   the  sides  of  the 
Fig.  34  a.       Fig.  34  b.      constriction  ring. 


ACCIDENTS  OF  HERNIA. 


121 


In  former  times,  herniotomy  was  regarded  as  a  highly 
dangerous  operation,  particularly  in  inguinal  and  femoral 
hernia,  on  account  of  the  fatal  intra-abdominal  hemor- 
rhages from  a  wounded  epigastric  or  obturator  artery. 
This  was  chiefly  due  to  the  fact  that  the  constriction  was 


Fig.  35. — The  division  of  the  constriction  from  within  outward. 


always  divided  from  mthin  outward  by  means  of  incisions 
from  one  to  two  centimeters  in  length.  If  the  previously 
stated  directions  are  followed,  such  unfortunate  cases  will 
not  occur,  and  even  if  a  vessel  is  wounded  its  immediate 
ligation  will  be  accomplished  without  difficulty. 


122  HERNIA. 

If  the  constriction  is  situated  outside  of  the  neck  of  the 
saCj  the  strangulation  may  be  relieved  by  the  division  of 
the  tissues  from  without  inward  without  opening  the  sac, 
and  this  operation,  known  as  external  herniotomy,  was 
formerly  frequently  employed.  It  is  scarcely  necessary  to 
state  that  such  a  course  is  admissible  only  in  those  cases  in 
which  the  short  duration  of  the  strangulation  and  the 
general  condition  of  the  patient  would  exclude  the  possi- 
bility of  the  presence  of  marked  changes  in  the  nutrition 
of  the  intestine.  Since  errors  of  judgment  are  possible  in 
such  cases,  it  is  safer  to  make  it  a  rule  to  always  open  the 
sac  and  form  an  opinion  of  the  condition  of  the  strangu- 
lated viscus  by  direct  inspection.  After  the  division  of 
the  constriction,  the  strangulated  intestinal  coil  should  be 
drawn  out  far  enough  to  allow  of  a  thorough  inspection 
of  the  constricted  portions,  but  great  care  must  be  observed 
in  making  traction  upon  the  intestine,  since  it  may  be  torn 
Avhere  it  has  been  thinned  and  weakened  by  the  strangula- 
tion. It  must  now  be  decided  whether  or  not  the  intestine 
may  be  safely  returned  into  the  abdomen.  If  omentum 
is  in  the  sac,  it  should  be  ligated  in  not  too  large  sections 
and  extirpated.  [If  the  omentum  is  in  fair  condition,  I 
believe  it  bad  judgment  to  prolong  the  operation  by  re- 
moving it. — Ed.]  If  intestine  is  in  the  sac,  there  are 
extreme  cases  in  which  it  may  be  said,  at  first  glance,  this 
intestinal  coil  will  surely  live,  or  that  one  is  gangrenous  ; 
but  there  are  also  intermediate  cases  in  which  correct  judg- 
ment is  very  difficult,  and  only  possible  after  a  long  exper- 
ience. It  is  extremely  difficult  and  often  impossible  to  lay 
down  definite  rules  in  these  cases.  After  the  relief  of  the 
constriction,  a  cyanotic,  bluish,  discolored  intestinal  coil 


ACCIDENTS  OF  HERNIA.  123 

should  be  enveloped  in  warm,  moist,  sterile  gauze  for  sev- 
eral minutes,  in  order  to  see  whether  it  recovers  and  takes 
on  its  normal  appearance.  As  long  as  the  intestinal  sur- 
face seems  smooth,  moist,  and  glistening,  as  long  as  the 
walls  are  elastic  and  return  to  their  original  position  when 
pinched  up  into  a  fold,  and  as  long  as  extensive  hemor- 
rhao^es  in  the  intestinal  wall  and  marked  chancres  in  the 
constricted  portions  are  wanting,  it  is  scarcely  to  be  sup- 
posed that  severe  disturbances  of  the  nutrition  of  the 
intestine  are  present.  In  the  remaining  doubtful  cases  a 
correct  decision  is  difficult  and  the  most  experienced  oper- 
ator is  liable  to  err.  The  most  deceptive  cases  are  those 
in  which  there  is  a  complete  elastic  strangulation  of  both 
the  arteries  and  the  veins,  since  a  few  hours  may  produce 
irreparable  damage,  which  in  the  beginning  is  scarcely 
manifested  in  the  intestinal  coil.  In  such  cases  the 
appearance  of  the  intestine  should  not  be  solely  relied 
upon,  but  the  general  condition  should  be  accurately 
observed.  Marked  shock  w^ith  a  small  rapid  pulse  is  one 
of  the  earliest  and  most  important  signs  of  a  severe 
strangulation  of  the  intestine  (see  page  101). 

The  reposition  is  best  made  by  forcing  the  contents  out 
of  the  herniated  intestine  by  compression  and  pushing  the 
portion  situated  nearest  to  the  hernial  orifice  into  the 
abdomen.  During  this  step  of  the  operation,  a  quiet  and 
uniform  anesthesia  is  of  the  utmost  importance  in  order 
that  the  viscera  may  not  be  repeatedly  forced  downward 
by  the  augmentations  of  the  intra-abdominal  pressure  pro- 
duced by  coughing  or  vomiting.  For  the  same  reason, 
when  the  operation  is  performed  under  local  anesthesia, 
the  patient  must  be  constantly  made  to  breathe  quietly  and 


124  HERNIA. 

evenly  with  his  mouth  open.  If  adhesions  exist  between 
the  intestine  and  the  sac,  they  must  be  cautiously  broken 
up,  or  if  this  is  not  possible,  the  portion  of  the  sac  which 
is  tightly  adherent  to  the  intestinal  coil  may  be  left 
behind  and  replaced  in  the  abdominal  cavity  together  with 
the  intestine. 

In  this  operation,  as  in  the  one  for  radical  cure,  the 
surgeon  must  be  prepared  to  meet  with  complications  of  a 
most  varied  character — a  subperitoneal  lipoma  may  simu- 
late omentum,  or  there  may  be  a  cyst  outside  of  and  ad- 
herent to  the  hernial  sac,  which  gives  the  impression  that 
an  empty  hernial  sac  itself  has  been  opened. 

If  there  is  the  slightest  suspicion  that  profound  nutri- 
tive disturbances  are  present  in  the  strangulated  intestinal 
coil,  it  should  never  be  reduced  until  it  has  been  entirely 
surrounded  by  strips  of  iodoform  gauze  the  ends  of  which 
are  brought  out  of  the  external  wound.  In  this  manner 
the  peritoneal  cavity  is  protected  from  infection.  In  such 
a  case  the  following  course  may  also  be  adopted :  The 
hernial  orifice  is  freely  incised,  the  intestinal  coil  is  envel- 
oped in  sterile  gauze,  and  allowed  to  remain  outside  of  the 
abdomen,  care  being  taken  that  the  retaining  dressing  is 
not  too  firmly  applied.  If  the  intestine  completely  recovers, 
and  if  the  wound  remains  aseptic,  the  intestine  may  be 
replaced  in  the  abdominal  cavity  after  a  few  days.  It  is 
self-evident,  however,  that  this  procedure  is  not  altogether 
safe  on  account  of  the  possible  danger  of  infection  of  the 
peritoneal  cavity. 

The  course  of  a  case  after  herniotomy  scarcely  differen- 
tiates itself  from  that  after  a  successful  taxis.  Ordinarily 
there  is  an  immediate  cessation  of  the  pain,  nausea,  and 


A CCIDENTS  OF  HERNIA.  125 

vomiting,  and  after  a  few  hours  flatus  is  passed.  Neither 
opiates  nor  purgatives  should  be  given  ;  if  the  bowels  are 
not  moved  spontaneously  after  twenty-four  hours,  a  small 
rectal  injection  of  glycerin  will  almost  always  produce  an 
evacuation.  The  most  frequent  source  of  trouble  after  the 
operation  is  inflammation  of  the  peritoneum,  and  in  the 
great  majority  of  cases  w^e  are  powerless  Avhen  confronted 
with  this  complication.  If  an  intestine  which  has  been 
considered  capable  of  life  and  returned  to  the  abdomen 
subsequently  undergoes  necrosis,  the  only  chance  of  avert- 
ing the  threatened  danger  is  by  an  immediate  laparotomy. 
Later  on,  after  a  herniotomy,  the  phenomena  of  intestinal 
occlusion  may  reappear,  and  this  may  be  due  to  angula- 
tions or  adhesions  of  the  reduced  intestinal  coil  or  to  the 
production  of  a  stenosis  by  the  sloughing  away  of  necrotic 
mucous  membrane.  The  only  treatment  of  such  conditions 
must,  of  course,  consist  of  a  further  operative  procedure. 
Mention  should  also  be  made  of  an  occurrence  which  is 
sometimes  observed  both  after  herniotomy  and  also  after 
the  radical  operation — the  inflammatory  tumor  of  the 
omentum.  These  tumors  may  even  occur  in  cases  in  which 
omentum  has  not  been  ligated  at  the  time  of  the  operation. 
Braun  has  quite  recently  directed  attention  to  this  form  of 
epiploitis  and  collected  the  previous  publications  upon  the 
subject.  Either  very  soon  after  the  operation  or  within  a 
few  weeks,  a  hard  irregular  intra-abdominal  tumor  is  felt 
which  usually  disappears  spontaneously  in  the  course  of  a 
few  months,  but  which  may  break  down  and  suppurate. 

The  pneumonias  which  not  infrequently  develop  after 
herniotomy  may  be  partly  referred  to  small  pulmonary 


126  HERNIA. 

embolisms,  the  emboli  being  derived  from  the  thrombosed 
vessels  of  the  hernial  region. 

If  the  intestinal  coil  is  gangrenous,  one  of  two  proce- 
dures must  be  adopted — either  the  resection  of  the  intes- 
tine or  the  making  of  an  artificial  anus.  It  is  only  in  very 
rare  and  exceptional  cases  that  it  is  allowable  to  invagi- 
nate  a  small  gangrenous  area  (such  as  the  decubitus  result- 
ing from  the  constriction)  and  sew  the  intestinal  w^alls 
together  over  the  invagination.  Before  such  a  course  may 
be  pursued  the  presence  of  marked  disturbances  of  nutri- 
tion in  the  remaining  portion  of  the  intestinal  coil  must  be 
absolutely  excluded. 

Without  considering  the  fact  that  the  general  condition 
of  the  patient  may  forbid  such  a  serious  operation  as  resec- 
tion of  the  intestine,  and  that  a  physician,  from  lack  of 
knowledge  of  the  technic  of  intestinal  operations,  or  for 
other  reasons,  must  satisfy  himself  with  the  making  of  an 
artificial  anus,  the  choice  of  operation  will  depend  upon 
which  one  offers  the  best  chance  of  recovery.  The  statis- 
tics at  our  disposal  for  the  purpose  of  forming  a  critical 
opinion,  however,  do  not  furnish  evidence  of  the  superior- 
ity of  either  method,  since  those  who  make  an  artificial 
anus  only  when  the  patient's  general  condition  is  so  bad 
that  the  more  severe  procedure  is  contraindicated  will  nat- 
urally report  but  little  good  from  the  operation.  The  fol- 
lowing statistics  are  the  most  recent  upon  the  subject,  and 
include  those  of  the  Gottingen  clinic  and  Braun's  cases 
from  1884  to  1900  inclusive : 


ACCIDENTS  OF  HERNIA. 


127 


Author  (Operator). 


V.  Bramann 

Sachs  (Kocher) 

Maydl 

Petersen  (Czerny)  .  .  .  . 
Gottinger  Klinik   (Konig, 

Braun) 

Braun 

Statistics  collected    by  v. 

Mikulicz 

Statistics  collected  by  Hof- 

meister 


M    , 

">  1 

W   5  «, 

H  » ;zi 

w<5  S 

55 

w  cu  o 

o  t,  2;  « 

^^' 

w  W 

F  Ca 

A    P 
ECTI 
ADE. 

°a  ^S 

•JO 

OK  wS 

w  o  < 
M  M  i-i  CO 

S« 

«^«« 

K  JD  U  < 

5  w 

K  K  K,  ->1 

g2^ 

66 

45.4% 

7 

85.0% 

25 

30 

46.0% 

15 

22 

67.0% 

28 

17 

88.2% 

21 

13 

76.9% 

22 

94 

76.6% 

68 

167 

60.5% 

99 

So 


60.0^ 
40.0% 
33.0% 

52.3% 
40.9% 

47.1% 

46.0% 


These  figures  would  speak  still  more  forcibly  for  pri- 
mary resection  if  the  results  obtained  in  recent  years  only 
were  taken  into  consideration,  since  in  this  time  there  has 
been  considerable  progress  in  the  operative  teclmic.  It 
might  be  mentioned  that  since  the  employment  of  the 
Murphy  button  and  the  performance  of  the  operation 
under  local  anesthesia,  Petersen  has  reported  twelve  pri- 
mary resections  of  the  intestine  in  the  Heidelberg  clinic, 
with  but  one  fatal  case,  thus  giving  a  mortality  of  8^. 

We  speak  of  an  artificial  anus  [anus  prceteimaturalis) 
when  the  entire  contents  of  the  intestine  are  emptied 
through  the  new  opening.  Such  a  condition  of  affairs 
must  obtain  after  the  sloughing  off  of  an  entire  intestinal 
coil.  If  only  a  portion  of  the  intestinal  wall  has  become 
gangrenous,  as  in  a  strangulated  hernia  of  the  intestinal 
wall,  for  example,  a  portion  of  the  feces  may  be  passed  in 


128  HERNIA. 

the  usual  manner,  and  we  call  this  condition  a  fecal  fistula 
(fistula  stercoral  is). 

If  it  has  been  decided  to  make  a  fecal  fistula  or  an  arti- 
ficial anus  in  a  case  of  gangrene  of  the  intestine,  the  con- 
striction is  divided  as  previously  described  in  the  operation 
of  herniotomy  and  the  strangulated  coil  is  drawn  out  far 
enough  to  prevent  its  constricted  portions  from  infecting 
the  peritoneal  cavity.  The  healthy  intestine  proximal  to 
the  constricted  portions  is  now  stitched  to  the  peritoneal 
surface  of  the  neck  of  the  sac  by  several  fine  silk  sutures 
which  penetrate  only  the  serous  and  muscular  coats  of  the 
intestine.  The  intestinal  coil  is  now  completely  surrounded 
by  iodoform  gauze,  which  is  also  stuffed  into  the  hernial 
orifice  in  order  to  completely  wall  off  the  peritoneal  cavity. 
When  this  has  been  thoroughly  accomplished,  the  coil  is 
freely  incised,  a  rather  thick  rubber  tube  is  passed  into  the 
afferent  intestine,  and  the  intestinal  contents  are  drawn  off 
into  a  vessel  without  infecting  the  wound  any  more  than 
can  be  avoided.  Whether  the  hernial  sac  should  or  should 
not  be  extirpated  in  such  a  case  depends  upon  the  degree 
in  which  the  purulent  inflammation  has  extended  to  the 
sac  and  upon  the  strength  of  the  adhesions.  In  all  cases, 
however,  the  entire  wound  should  be  packed  with  iodoform 
gauze  and  kept  open  in  such  a  manner  that  a  retention  of 
the  wound  products  is  impossible. 

If  only  a  fecal  fistula  is  made,  a  spontaneous  cure  may 
sometimes  result,  since  the  intestine  may  draw  away  from 
the  abdominal  wall,  and  the  canal  situated  between  the  in- 
testinal and  cutaneous  wounds  gradually  narrows,  becomes 
filled  with  granulation  tissue,  and  finally  cicatrizes.  These 
canal-like  fecal  fistulas  must  be  differentiated  from  the  lip- 


A  CCI DENTS  OF  HERNIA .  129 

like  fistulas,  in  which  the  intestinal  mucous  membrane 
passes  directly  into  the  edges  of  tlie  cutaneous  wound.  In 
such  cases  a  cure  can  only  be  accomplished  after  the  epi- 
thelial covering  of  the  fistula  has  been  destroyed  by  cauter- 
ization or  by  extirpation.  Sometimes  even  this  measure 
will  fail,  and  then  nothing  is  left  but  the  separation  of  the 
intestinal  coil  from  the  abdominal  wall  and  the  closure  of 
the  intestinal  and  cutaneous  orifices,  an  operation  which  is 
not  absolutely  free  from  danger  on  account  of  the  reopen- 
ing of  the  abdominal  cavity. 

The  production  of  an  artificial  anus  is  only  a  makeshift, 
to  be  employed  in  extreme  cases,  since  the  nutrition  of  the 
patient  suffers  severely,  particularly  if  the  intestine  has 
been  strangulated  high  up  and  its  contents  are  evacuated 
before  the  greater  portion  of  the  nutritive  material  can  be 
absorbed.  If  the  artificial  anus  cannot  soon  be  closed  and 
the  intestinal  contents  allowed  to  pursue  their  usual  course, 
the  patient  emaciates  and  yery  soon  dies  from  inanition. 
The  chief  obstacle  to  the  passage  of  feces  from  the  afferent 
into  the  efferent  intestine  is  due  to  the  fact  that  the  poste- 
rior wall  of  the  opened  intestinal  coil,  together  with  its 
mesentery,  project  anteriorly  like  a  spur,  and,  as  shown  in 
figure  36,  form  a  complete  partition  betw^een  the  proximal 
and  the  distal  ends  of  the  intestine.  If  this  spur  can  be 
removed  so  that  the  intestinal  contents  can  pass  into  the 
efferent  intestine,  the  case  may  be  converted  into  a  fecal 
fistula,  and  a  complete  cure  may  be  much  more  readily 
obtained.  Figure  36  illustrates  the  method  followed  by 
Dupuytren  in  the  treatment  of  these  cases.  The  branches 
of  the  enterotome  are  passed  into  the  lumina  of  the  intes- 
tine and  the  spur  is  slowly  destroyed  by  pressure  applied 
9 


130  HERNIA. 

by  means  of  the  external  screw.  The  same  principle  has 
been  employed  in  the  newer  and  better  clamps  of  v.  Miku- 
licz and  of  Krause.  These  clamps  do  not  protrude  through 
the  external  wound,  and  eifect  an  anastomosis  further  pos- 
teriorly. The  main  objection  to  any  of  these  clamps  is  that 
ihQ  work  is  done  in  the  dark,  since  it  can  never  be  known 
whether  some  viscus  has  not  slipped  in  between  the  afferent 
and  efferent  intestine,  to  be  subjected  to  crushing  when  the 
compression  is  made  upon  the  spur.  In  the  majority  of 
cases  the  intestine  must  be  secondarily  sutured,  or,  if  this 
is  contraindicated  by  the  possible  formation  of  a  stricture, 
resection  of  the  intestine  or  enteroplasty  as  recommended 
by  Braun. 

Without  considering  the  nutritive  loss  when  the  affected 
intestine  is  situated  high  up,  the  condition  of  a  patient  with 
an  artificial  anus  is  extremely  annoying  both  to  himself 
and  to  his  associates.  This  is  due,  in  no  small  measure,  to 
the  fact  that  the  escaping  intestinal  contents — chiefly  those 
of  the  small  intestine — irritate  the  skin  and  sometimes  pro- 
duce an  extremely  painful  and  annoying  eczema,  which 
may  extend  over  a  large  area  about  the  artificial  anus. 
This  condition  must  be  borne  in  mind  and  the  skin  pro- 
tected by  the  application  of  thick  layers  of  some  ointment. 
The  best  combination  for  this  purpose  is  one  of  zinc  oxid 
and  olive  oil,  which  are  mixed  in  such  proportions  that 
they  form  a  thick  paste.  The  cure  of  an  eczema  after  it 
has  developed  is  frequently  very  difficult  to  attain.  The 
treatment  with  salves  is  often  ineffectual,  and  the  best 
results  are  obtained  by  the  permanent  water-bath,  the 
employment  of  which  will  usually  effect  a  cure  within  a 
few  days. 


ACCIDENTS  OF  HERNIA. 


131 


Fig.  36. — Artificial  anus  with  Dupuytren's  enterotome  applied  for 
the  purpose  of  destroying  the  spur. 


132 


HERNIA. 


A  good  protective  dressing  for  an  artificial  anus  is  shown 
in  figure  37  a.  It  is  made  upon  the  same  plan  as  a  spring 
truss,  the  pad  being  replaced  by  a  metallic  capsule  contain- 


Fig.  37  a. 

ing  a  changeable  rubber  ring  (Fig.  37  b)  which  may  be 
filled  with  air.  This  ring  may  be  pressed  so  firmly  against 
the  skin  that  the  closure  is  perfect  and  its  cavity  will 

accommodate    a    certain 
amount  of  feces  without 
f  ff^^  "^s.  annoyance  to  the  patient. 

Such  an    appliance    will 

retain  solid  feces  at  least, 

and    in    favorable    cases 

Fig.  37  b.  even  allow  the  patient  to 

fulfil  his  social  duties. 
If  it  has  been  decided  to  resect  the  intestine,  it  must 
be  particularly  remembered  that  the  nutritive  disturbances 
extend  upward  a  considerable  distance  above  the  constricted 
portion  of  the  afferent  intestine.  This  is  chiefly  due  to  the 
marked  distention  on  the  proximal  side  of  the  strangula- 


ACCIDENTS  OF  HERNIA.  133 

tion.  The  walls  of  the  intestine  become  very  friable,  and 
this  is  especially  noticed  by  the  tearing  through  of  the 
sutures  if  much  tension  is  placed  upon  them.  In  such  a 
case  the  resection  of  the  afferent  end  must  be  made  high  up 
in  healthy  tissue. 

Individual  operators  lay  great  stress  upon  the  thorough 
irrigation  of  the  afferent  intestine  in  order  to  draw  off  the 
stao^nant  intestinal  contents  before  the  ends  of  the  resected 
intestine  are  united.  The  wound  must  be  firmly  packed 
with  gauze  to  protect  it  from  accidental  contact  with  feces, 
a  soft  esophageal  tube  is  introduced  high  up  into  the  affer- 
ent end  of  the  intestine,  and  the  intestine  is  irrigated. 
The  esophageal  tube  should  project  well  beyond  the  wound 
so  that  the  irrigation  fluid  can  flow  into  a  receptacle  with- 
out infecting  the  site  of  the  operation.  [I  do  not  believe 
this  necessary,  and  in  many  cases  it  may  do  harm,  as  much 
of  the  fluid  may  remain  in  the  intestine  and  cause  disten- 
tion.— Ed.] 

In  cases  in  which  the  intestine  is  suspected  of  being 
gangrenous,  Helferich  has  suggested  that  the  intestinal 
coil  be  drawn  out  far  enough  to  make  an  entero-anastomosis 
between  the  afferent  and  efferent  intestines  a  hand's-breadth 
above  the  site  of  the  previous  constriction,  and  that  the 
intestine  then  be  replaced  so  that  only  the  suspected  portion 
remains  outside.  If  necrosis  does  not  occur  within  twenty- 
four  or  forty-eight  hours,  this  coil  may  also  be  returned 
to  the  abdomen  ;  if  the  intestine  becomes  gangrenous,  only 
a  portion  of  the  intestinal  contents  will  escape  through  the 
wound,  the  other  portion  being  able  to  pass  on  through 
the  anastomosis.  This  procedure  is  to  \>q  particularly 
recommended  when  the  strangulation  is  situated  high  up 


134  HERNIA. 

and  the  general  condition  of  the  patient  will  not  permit  of 
an  operation  requiring  so  much  time  as  an  intestinal  resec- 
tion. 

A  description  of  the  technic  of  intestinal  resection  can- 
not be  given,  since  it  would  carry  us  far  beyond  the  limits 
of  this  atlas,  and  we  must  consequently  refer  the  reader  to 
the  text-books  upon  operative  surgery.  The  choice  of  the 
method  by  which  the  stumps  are  united  after  the  resection 
of  the  gangrenous  intestine,  whether  they  should  be  united 
by  suture  or  by  the  Murphy  button,  whether  the  efferent 
end  should  be  closed  and  the  afferent  end  implanted  later- 
ally in  the  former,  or  whether  both  ends  should  be  closed 
and  a  lateral  anastomosis  made,  depends  so  much  upon  the 
inclination  and  habit  of  the  operator  that  general  rules 
upon  these  points  cannot  be  given. 

Is  it  allowable  to  perform  the  radical  operation  imme- 
diately after  a  herniotomy  ?  Such  a  course  could  only  be 
pursued  if  the  strangulated  intestine  were  found  quite 
intact  and  if  all  of  the  phenomena  of  inflammation  were 
absent.  We  know  that  the  result  of  the  radical  operation 
is  in  no  small  degree  dependent  upon  the  aseptic  condition 
of  the  wound,  and  it  is  clear  that  the  preparation  of  the 
patient  by  baths,  by  antiseptic  fomentations  over  the  her- 
nial region,  and  by  a  sufficient  evacuation  of  the  bowels 
can  be  much  more  thoroughly  carried  out  before  the  radi- 
cal operation  than  is  possible  in  any  operation  upon  a 
strangulated  hernia.  It  consequently  follows  that  in  all 
cases  in  which  a  resection  of  the  intestine  must  be  made 
it  is  well  to  omit  the  immediate  performance  of  the  oper- 
ation for  radical  cure. 


EXPERT  OPINIONS.  135 

EXPERT  OPINIONS  IN  REFERENCE  TO 
ABDOMINAL  HERNIAS. 

The  essential  poiuts  in  reference  to  a  causal  connection 
between  accident  and  hernia  have  been  sufficiently  empha- 
sized upon  pages  53—57.  If  it  is  evident  from  the  princi- 
ples previously  discussed  that  such  a  connection  does  exist, 
the  determination  of  the  amount  of  the  loss  in  earning 
power  will  depend  upon  the  condition,  size,  and  reducibil- 
ity  of  the  hernia.  As  stated  by  the  Government  Insurance 
Bureau  (Reichs-Versicherungsamt),  even  a  small  reducible 
hernia  prevents  the  individual  from  utilizing  certain  oppor- 
tunities of  gaining  a  livelihood  and  debars  him  from  using 
all  his  strength  in  his  chosen  occupation.  He  is  forced  to 
wear  a  good  truss,  to  see  that  it  permanently  retains  the 
hernia,  and,  finally,  to  always  remember  his  physical  weak- 
ness in  his  work  and  in  his  selection  of  an  occupation. 
The  earning  power  of  an  individual  with  a  reducible  her- 
nia perfectly  retained  by  a  truss  is  assumed  to  be  dimin- 
ished about  10^.  The  loss  in  earning  power  becomes 
correspondingly  greater  if  the  hernia  is  retained  by  a  truss 
with  difficulty,  and  particularly  if  it  is  irreducible  and  of 
large  dimensions.    . 

It  has  already  been  briefly  mentioned  that  inguinal  her- 
nias have  been  artificially  produced.  It  is  stated  that  in 
Russia  these  inguinal  hernias  are  brought  about  by  trau- 
matisms in  order  to  render  the  individual  unfit  for  military 
duty,  and  a  considerable  literature  upon  the  subject  already 
exists.  Very  recently  Galin  has  collected  these  observa- 
tions and  published  them,  together  with  his  own  experi- 
mental investigations.     Galin  states  that  a  path  for  the 


136  HERNIA. 

descent  of  an  inguinal  hernia  can  undoubtedly  be  produced 
by  an  intentional  injury.  It  is  probable  that  an  instru- 
ment like  a  glove-stretcher  is  introduced  into  the  inguinal 
canal,  and  that  by  its  use  the  canal  can  be  dilated  and  that 
extensive  lacerations  of  the  external  abdominal  ring  and 
of  the  aponeurosis  of  the  external  oblique  muscle  can  be 
produced.  Galin  demonstrated  on  the  cadaver  that  with 
the  aid  of  such  an  instrument  the  columns  of  the  external 
ring  can  be  torn  ;  if  the  canal  is  so  narrow  that  the  instru- 
ment cannot  be  introduced,  the  aponeurosis  of  the  external 
oblique  may  be  torn  at  some  distance  from  the  external 
abdominal  ring  by  the  application  of  considerable  force. 
Such  a  laceration  can  easily  be  enlarged  by  introducing  the 
finger,  and  if  the  finger  is  pushed  further  inward,  the  path 
for  the  hernia  may  easily  be  made.  The  characteristics 
of  such  an  artificially  produced  inguinal  hernia  are  that  it 
corresponds  more  nearly  to  the  type  of  an  internal  inguinal 
hernia ;  that  the  external  hernial  orifice,  which  is  either  at 
the  external  abdominal  ring  or  at  an  abnormal  opening  in 
the  external  oblique  muscle,  feels  irregularly  thickened 
from  inflammatory  exudate ;  and  that  intense  pain  is  usu- 
ally caused  when  the  finger  is  introduced  well  into  the 
hernial  canal. 

In  conclusion,  the  existing  regulations  of  the  German 
army  and  navy  in  reference  to  the  fitness  for  service  of 
individuals  with  liernia  will  be  given,  as  well  as  those 
which  apply  to  the  Austrian  and  Swiss  troops. 

GERMANY. 
1.  The  simple  dilatation  of  the  external  abdominal  ring, 
designated  as  a  predisposition  to  the  development  of  a  her- 


EXPERT  OPINIONS.  137 

nia,  or  the  bulging  of  the  thinned  anterior  abdominal  wall 
in  the  region  of  the  hernial  canal  produced  by  coughing, 
does  not  render  the  individual  unfit  for  service  with 
weapons. 

2.  One-year  volunteers  and  volunteer  color-bearers  who 
have  hernias  that  are  easily  and  securely  retained  by  trusses 
can  be  enrolled  if  they  so  desire,  ?nd  if  the  commander  of 
the  troops,  acting  upon  the  suggestion  of  the  army  surgeon, 
is  willing  to  accept  their  service. 

3.  A  simple  inguinal  hernia  capable  of  being  retained 
by  a  truss  does  not  render  the  individual  unfit  for  service 
without  weapons,  but  does  disqualify  him  for  service  in  the 
Commissary  Department  in  the  field. 

4.  Individuals  with  fully  developed  abdominal  hernias 
which  can  be  retained  by  a  truss,  and  also  those  with  her- 
nias which  are  still  within  the  inguinal  canal,  are  disquali- 
fied for  service  in  the  standing  army  and  in  the  reserve 
army ;  they  are,  on  the  contrary,  usually  fit  for  service  in 
the  last  reserve  corps. 

5.  Individuals  with  fully  developed  abdominal  hernias 
which  cannot  be  retained  by  a  truss  on  account  of  their 
size  and  adhesions  are  disqualified  for  service  in  the  stand- 
ing army,  in  the  reserve  army,  and  usually  also  in  the  last 
reserve  corps.  Such  hernias  also  render  members  of  the 
Commissary  Department  unfit  for  service  in  the  garrison 
and  upon  the  field. 

6.  If  individuals  not  in  active  service  but  serving  as 
helpers  develop  a  simple  hernia  which  is  easily  retained  by 
a  truss,  they  shall  not  be  disqualified  on  this  account  until 
their  legal  time  of  service  has  expired. 


138  HERNIA. 

AUSTRIA. 

1.  Bulgings  in  the  inguinal  region  and  dilatations  of  the 
inguinal  canal^  provided  that  the  viscera  do  not  descend 
into  the  canal,  and  that  the  individual  is  otherwise  well- 
built,  do  not  disqualify  the  individual  from  service  in  time 
of  war. 

2.  Visceral  protrusions  (hernias),  regardless  of  their  size 
and  length  of  duration,  absolutely  disqualify  the  individual 
for  service  in  time  of  war. 

SWITZERLAND. 

Any  variety  of  abdominal  hernia  renders  the  individual 
so  afflicted  unfit  for  military  service.  (The  presence  of  an 
inguinal  hernia  is  to  be  assumed  if  the  inguinal  canal  be- 
comes filled  under  the  influence  of  augmentations  of  the 
intra-abdominal  pressure.) 

An  abdominal  hernia  developing  during  the  time  of 
service  can  disqualify  the  individual  only  when  it  cannot 
be  completely  and  permanently  retained  by  a  truss. 


SPECIAL  HERNIAS- 


INGUINAL  HERNIA. 

The  inguinal  hernia  is  the  most  frequent  of  all  varieties, 
and,  according  to  Berger,  96  ^  of  all  male  individuals  who 
have  single  or  multiple  hernias  are  afflicted  with  this  type, 
the  corresponding  percentage  among  females  being  44.3  ^ . 

ANATOMY, 
By  the  inguinal  region  we  understand  that  portion  of 
the  abdominal  wall  which  is  situated  immediately  above 
Poupart's  ligament.  This  ligament  extends  from  the  ante- 
rior superior  spine  of  the  ilium  to  the  spine  of  the  pubis, 
and  is  nothing  more  nor  less  than  the  lower  free  border 
of  the  aponeurosis  of  the  external  oblique  muscle,  strength- 
ened by  bands  of  connective  tissue  which  radiate  to  the 
ligament  from  the  surrounding  tissues.  The  external  ab- 
dominal ring  is  shown  in  figure  3,  and  is  formed  by  the 
semicircular  edge  of  the  external  oblique  muscle.  This 
ring  is  the  external  orifice  of  the  inguinal  canal ;  it  is  the 
point  at  which  inguinal  hernia  appears  externally,  and,  as 
shown  in  figure  1 7,  can  be  palpated  in  the  male  by  invag- 
inating  the  skin  of  the  scrotum.  In  the  female  the  inguinal 
canal  gives  passage  to  the  round  ligament ;  in  the  male  it 
is  filled  up  by  the  spermatic  cord,  surrounded  by  loose 
connective  tissue,  and  indicates  the  path  which  has  been 

139 


140  HERNIA. 

Fig.  38. — Oblique  section  passing  through  the  anterior  superior 
spine  of  the  ilium  and  the  spine  of  the  j)ubis,  so  that  the  inguinal 
canal  is  laid  open,  exposing  the  spermatic  cord  in  its  entire  course 
through  the  abdominal  wall  from  the  internal  to  the  external  alxiom- 
inal  ring  :  a,  External  abdominal  ring  ;  b,  sciatic  nerve  ;  c,  obturator 
vessels  and  nerve ;  d,  gland  of  Rosenmiiller ;  e,  acetabulum ;  f, 
femoral  vein  ;  g,  spermatic  cord  within  the  inguinal  canal ;  h,  femoral 
artery ;  i,  anterior  crural  nerve ;  k,  iliopsoas  muscle ;  1,  Poupart's 
ligament;  m,  transversalis  muscle;  n,  internal  oblique  muscle;  o, 
external  oblique  muscle. 

taken  by  the  testicle  in  its  descent  from  the  abdominal 
cavity  into  the  scrotnm.  The  canal  passes  obliquely 
through  the  anterior  abdominal  wall  parallel  to  Poupart's 
ligament  and  is  from  four  to  five  centimeters  in  length. 
In  children  the  canal  is  shorter  and  more  direct,  so  that 
the  internal  abdominal  ring  lies  almost  directly  behind  the 
external  abdominal  ring.  Throughout  the  entire  inguinal 
canal,  the  spermatic  cord  is  covered  anteriorly  by  the  exter- 
nal oblique  muscle ;  the  internal  oblique  muscle  partly 
surrounds  the  cord  and  sends  some  of  its  fibers,  which  are 
known  as  the  cremaster  muscle,  down  to  the  testicle  (Fig. 
4).  In  figure  5  the  spermatic  cord  is  seen  making  its  exit 
from  beneath  the  free  edge  of  the  transversalis  muscle, 
and  figure  6  shows  the  internal  abdominal  ring,  which  has 
been  exposed  by  the  removal  of  this  muscle.  The  oblique 
course  of  the  spermatic  cord  is  still  more  distinctly  shown 
by  figure  38. 

As  is  seen  in  figure  38,  the  spermatic  cord  within  the 
inguinal  canal  is  bounded  posteriorly  by  Poupart's  liga- 
ment, anteriorly  for  a  short  distance  by  the  internal  oblique 
muscle,  and  for  the  remainder  of  its  course  by  the  a])oneu- 
roses  of  the  abdominal  muscles.     The  cord  leaves  the  ab- 


/^ 


INGUINAL  HERNIA.  141 

dominal  cavity  through  the  internal  abdominal  ring,  passes 
through  the  abdominal  wall,  and  leaves  the  same  through 
the  external  abdominal  ring. 

A  study  of  the  inner  surface  of  the  anterior  abdominal 
wall  is  of  particular  importance  for  tlie  correct  under- 
standing of  inguinal  hernia  (Plate  2). 

The  peritoneum  of  the  anterior  abdominal  wall  is  lifted 
up  into  folds  by  several  cords  which  are  situated  between 
it  and  the  transversalis  fascia,  and  these  folds  divide  the 
surface  into  various  fossae.  Of  these  folds,  there  are  three 
which  are  well  marked,  particularly  in  the  young,  and 
w^hich  pass  from  the  sides  and  apex  of  the  bladder  to 
the  umbilicus.  The  middle  fold — plica  vesico-umbilicalis 
media — is  caused  by  the  remains  of  the  urachus  or  the 
duct  of  communication  between  the  bladder  and  the  um- 
bilicus ;  the  lateral  folds — plicae  vesico-umbilicales  later- 
ales — are  caused  by  the  obliterated  hypogastric  arteries. 
Still  more  laterally  situated  is  a  less  prominent  fold,  which 
does  not  extend  quite  to  the  umbilicus.  It  is  known  as  the 
plica  epigastrica,  and  is  caused  by  the  epigastric  artery  (a 
branch  of  the  external  iliac)  and  its  accompanying  veins. 
To  the  outer  side  of  the  plica  epigastrica  there  is  a  more 
or  less  markedly  developed  fossa,  the  external  inguinal 
fossa,  which  is  the  place  of  exit  of  the  external  inguinal 
hernia ;  to  the  inner  side  of  the  plica  epigastrica  there  is  a 
similar  fossa,  the  internal  inguinal  fossa,  and  this  is  the 
place  of  exit  of  the  internal  inguinal  hernia.  A  fossa  is 
sometimes  encountered  between  the  median  and  lateral 
vesico-umbilical  folds,  and  this  is  known  as  the  supraves- 
ical fossa.  The  external  and  internal  inguinal  fossae  are 
those  in  wdiich  we  are  chiefly  interested. 


142  HERNIA. 

PLATE  2. 
The  Internal  Aspect  of  the  Anterior  Abdominal  Wall  of  a 
Newborn  Male  Child. — The  anterior  abdominal  wall  has  been  ele- 
vated and  put  upon  the  stretch,  while  the  posterior  abdominal  wall 
has  been  divided  by  a  transverse  section  at  the  level  of  the  third  lum- 
bar vertebra,  a,  Hypogastric  vein  ;  b,  plica  vesico-umbilicalis  later- 
alis ;  c,  plica-vesico-umbilicalis  media ;  d,  plica  epigastrica  (deep 
epigastric  artery)  ;  e,  urinary  bladder  ;  f,  external  inguinal  fossa  ;  g, 
internal  inguinal  fossa  ;  h,  vas  deferens  ;  i,  rectum  ;  k,  spermatic  ves- 
sels ;  1,  ureter  ;  m,  common  iliac  artery  ;  n,  common  iliac  vein. 

Figure  39  represents  the  conditions  which  obtain  when 
an  external  and  an  internal  inguinal  hernia  are  present. 
The  entire  peritoneum  has  been  removed  with  the  excep- 
tion of  the  two  funnel-like  diverticula  which  pass  out  to 
form  the  hernial  sacs.  In  the  external  inguinal  fossa/ and 
consequently  to  the  outer  side  of  the  deep  epigastric  artery, 
the  structures  which  form  the  spermatic  cord — i.  e.,  the 
spermatic  vessels  and  the  vas  deferens — pass  into  the 
inguinal  canal  together  with  the  external  inguinal  hernia. 
To  avoid  subsequent  confusion,  one  point  must  be  clearly 
noted,  and  that  is  that  the  internal  abdominal  ring  is  situ- 
ated within  the  external  inguinal  fossa.  The  hernia  which 
passes  out  with  the  spermatic  cord  is  known  as  the  exter- 
nal, the  oblique,  or  the  indirect  hernia. 

The  hernia  protruding  through  the  internal  inguinal 
fossa,  and  consequently  to  the  inner  side  of  the  deep  epi- 
gastric artery,  does  not  pass  through  a  previously  formed 
canal ;  it  passes  directly  forward  through  the  abdominal 
wall,  and  is  known  as  an  internal  or  direct  inguinal 
hernia. 

In  very  rare  cases  an  inguinal  hernia  passes  out  through 
the  supravesical  fossa  and  appears  at  the  external  abdom- 


I'ah.'I. 


Ltth.  Aast.  /.■  Reuniivui.  .unnawn 


INGUINAL  HERNIA.  143 

inal  ring  after  passing  obliquely  through  the  abdominal 
wall.  This  form  of  hernia,  together  with  a  few  poorly 
described  cases  in  which  the  hernial  sac  descended  partly 
parallel  to  the  inguinal  canal  and  partly  by  means  of  a 
diverticulum  into  the  opposite  half  of  the  scrotum,  are  such 
great  exceptions  that  it  will  be  sufficient  to  simply  mention 
the  condition. 

In  the  female  inguinal  hernia  is  considerably  rarer  than 
in  the  male,  and  this  is  due  to  the  narrowness  of  the 
inguinal  canal,  which  accommodates  nothing  but  the  round 
ligament,  a  structure  which  is  much  smaller  than  the 
spermatic  cord. 

EXTERNAL  OBLIQUE  INGUINAL  HERNIA. 

The  external  inguinal  hernia  may  be  either  congenital 
or  acquired.  The  congenital  predisposition  to  such  a 
hernia  bears  a  most  intimate  relation  to  the  conditions 
which  obtain  with  reference  to  the  descent  of  the  testicle. 

Congenital  Inguinal  Hernia. — Figure  40,  a,  repre- 
sents the  conditions  as  they  are  found  at  about  the  fourth 
month  of  fetal  life.  The  testicle  has  developed  within 
the  abdomen  and  is  located  behind  the  peritoneum.  The 
same  picture  shows  that,  independent  of  the  subsequent 
descent  of  the  testicle,  a  peritoneal  diverticulum  has 
formed  in  the  inguinal  region  in  the  situation  correspond- 
ing to  what  is  later  knowm  as  the  vaginal  process  of  the 
peritoneum.  In  the  female  there  is  also  such  a  peritoneal 
diverticulum,  designated  as  the  diverticulum  of  Nuck,  but 
such  an  open  peritoneal  process  at  the  time  of  puberty  is 
one  of  the  greatest  rarities  (Merkel).  During  the  sixth 
and  seventh  months  of  fetal  life  (Fig.  40,  b)  the  testicle 
gradually  descends,  and  at  the  ninth  month  has  reached 


144  HERNIA. 

Fig.  39. — External  and  internal  inguinal  hernias,  seen  from  within  : 
a,  Psoas  muscle  ;  b,  rectum  ;  c,  external  iliax?  vein  ;  d,  external  iliac 
artery  ;  e,  urinary  bhulder  ;  f,  sac  of  an  external  inguinal  hernia  ;  g, 
spermatic  cord  ;  h,  sac  of  an  internal  inguinal  hernia  ;  i,  epigastric 
artery  ;  k,  rectus  abdominis  muscle. 

the  bottom  of  the  scrotum  (Fig.  40,  c).  In  this  manner 
the  testicle  pushes  the  transversalis  fascia  down  ahead  of 
it,  and  this  fascia  consequently  invests  the  testicle  and 
spermatic  cord  as  the  tunica  vaginalis  communis.  The  cord 
and  testicle  are  also  surrounded  by  the  fibers  of  the  cre- 
master  muscle,  which  are  derived  from  the  internal  oblique 
and  transversalis  muscles.  At  this  time  the  process  of 
peritoneum  which  has  been  drawn  down  is  still  in  com- 
munication with  the  peritoneal  cavity,  and  this  canal-like 
communication  is  known  as  the  processus  vaginalis  peritonei. 
Before  birth  the  walls  of  this  vaginal  process  become 
adherent,  so  that  on  one  side  the  parietal  peritoneum 
passes  smoothly  over  the  internal  abdominal  ring,  while 
on  the  other  the  closed  serous  sac  is  adherent  to  the 
anterior  surface  of  the  testicle  and  forms  the  tunica  vagi- 
nalis propria  (Fig,  40,  d).  If  this  obliteration  of  the 
processus  vaginalis  does  not  occur,  there  is  a  congenital 
hernial  sac,  as  shown  in  figure  40,  c,  and  this  may  become 
a  hernia,  either  at  birth  or  in  later  life,  by  the  descent  of 
some  of  the  viscera  (Plate  3). 

The  following  figures,  taken  from  Bayer,  show  the  fre- 
quency of  these  disturbances  of  development  as  well  as  the 
differences  which  are  observed  between  the  right  and  left 
sides  of  the  body. 

In  70  newborn  males.  Camper  found  the  vaginal  process 
patulous  upon  both  sides  34  times,  upon  the  right  side  14 
times,  and  upon  the  left  side  8  times. 


Fig.  30. 


a -^ 


b  - 


INGUINAL  HERNIA.  145 

In  100  newborn  children,  Engel  found  the  process  patu- 
lous upon  both  sides  60  times,  upon  the  right  side  30  times, 
and  closed  in  all  cases  upon  the  left  side. 

Zuckerkandl  examined  the  bodies  of  100  children  (first 
to  the  twelfth  week)  and  found  a  patulous  process  upon 
both  sides  20  times,  upon  the  right  side  12  times,  and  upon 
the  left  side  5  times. 

In  102  inguinal  hernias,  Felizet  found  63  cases  upon  the 
right,  and  39  cases  upon  the  left  side.  It  is  beheved  that 
the  reason  for  the  preponderance  upon  the  right  side  is 
due  to  the  fact  that  the  left  testicle  descends  into  the  scro- 
tum at  an  earlier  period  than  the  right.  Weil  thinks  that 
the  earlier  descent  of  the  left  testicle  is  probably  due  to 
the  pressure  of  the  full  sigmoid  colon. 

The  causes  for  the  non-closure  of  the  vaginal  process 
are  sometimes  to  be  found  in  disturbances  connected  with 
the  descent  of  the  testicle,  and  such  inguinal  hernias  are 
therefore  not  infrequently  found  in  combination  with  cryp- 
torchism.  Another  explanation  for  the  condition  is  that 
some  viscus  becomes  adherent  to  the  peritoneal  covering 
of  the  testicle  within  the  abdomen,  and  that  it  is  drawn 
down  by  the  descent  of  this  organ. 

The  possibilities  of  a  congenital  predisposition  to  her- 
nias have  not  been  exhausted  by  the  varieties  of  congeni- 
tal inguinal  hernia  which  have  just  been  described.  Still 
other  forms  are  possible,  and  they  will  receive  particular 
attention  in  the  description  of  the  combinations  of  hernia 
with  hydrocele  (page  161). 

Bayer  has  recently  directed  attention  to  a  number  of 
anatomic  peculiarities  of  the  congenital  inguinal  hernia, 
some  of  which  were  previously  know^n.  Of  these  pecu- 
liarities, the  following  might  be  mentioned  : 

1.  The  absence  of  the  layer  of  subperitoneal  fat,  in 
10 


146  HERNIA. 

Fig.  40. — The  descent  of  the  testicle  (Stieda-Pansch) :  a,  Position 
of  the  testicle  at  about  the  fourth  month  of  fetal  life ;  b,  position  of 
the  testicle  at  about  the  sixth,  and  until  the  seventh  month  of  fetal 
life  ;  c,  position  of  the  testicle  in  the  ninth  month  of  fetal  life  ; 
origin  of  the  vaginal  process  of  the  peritoneum  ;  d,  position  of  the 
testicle  at  birth  ;  origin  of  the  tunica  vaginalis  propria. 

consequence  of  which  the  sac  is  more  firmly  attached  to 
the  hernial  coverings  and  seems  to  be  adherent  to  them. 
For  this  reason  the  extirpation  of  the  sac  is  more  difficult 
than  in  acquired  hernias. 

2.  The  spermatic  cord  is  not  found  as  a  connected 
bundle  beside  the  hernial  sac,  but  is  rather  frayed  out ;  its 
blood-vessels  frequently  lie  side  by  side,  usually  covering 
the  entire  external  and  posterior  surface  of  the  sac,  while 
the  vas  deferens  is  almost  always  isolated  and  situated 
behind  the  hernial  sac, 

3.  The  cremaster  muscle  forms  a  connected  muscular 
covering  which  is  intimately  associated  with  the  tunica 
vaginalis  communis  about  the  hernial  sac.  In  acquired 
hernias  the  muscular  .  fibers  are  separated  and  very  fre- 
quently interrupted  in  their  course. 

4.  The  aponeurosis  bf  the  external  oblique  muscle  does 
not  form  an  external  abdominal  ring  with  sharp  tendinous 
borders,  but  is  continued  for  a  distance  upon  the  layer  of 
cremaster  muscle  as  a  veil-like  membrane. 

A  clinical  characteristic  of  the  presence  of  a  congenital 
sac  is  found  in  the  fact  that  when  a  hernia  first  appears  in 
such  patients  it  descends  very  rapidly  as  far  as  the  scrotum, 
while  the  descent  of  an  acquired  hernia  is  usually  extremely 
slow. 

Acquired  External  Inguinal  Hernia. — As  a  matter 


Pcr'don 


Fig.  40. 


a. 


b. 


Proc.  vagw 
peritonei 


Tumeavagln 
propria^ 


Turned  vagtn. 
coinmunis 


Tunica 
vaginal. 
propria 


Tunica  vaginal, 
communis 


INGUINAL  HERNIA.  147 

of  fact,  it  is  extremely  probable  that  many  of  the  hernias 
which  we  classify  as  acquired  cannot  be  so  designated. 
We  have  seen  (page  18)  that  the  number  of  hernias  in  the 
second  and  third  years  of  life — and  these  hernias  are 
almost  without  exception  of  the  inguinal  variety — is  extra- 
ordinarily smaller  than  during  the  first  year,  and  we  have 
reason  to  suppose  that  in  very  many  of  these  cases  an 
adhesion  and  obliteration  of  the  vaginal  process  has  not 
taken  place,  but  that  this  process  has  simply  become  much 
narrowed,  and  that  the  descent  of  the  viscera  into  the  sac 
is  consequently  prevented.  If  the  abdominal  walls  become 
relaxed  with  advancing  years,  and  if  the  occupation  or  a 
disease  causes  frequent  and  marked  augmentations  of  the 
intra-abdominal  pressure,  the  narrowed  entrance  to  the 
sac  can  become  dilated  again  and  a  hernia  develops  which 
is  apparently  acquired,  but  the  predisposition  to  which  was 
nevertheless  congenital. 

The  acquired  external  inguinal  hernia  follows  the  course 
of  the  spermatic  cord  and  may  stop  at  any  point  in  its 
descent.  If  the  hernia  remains  Avithin  the  inguinal  canal, 
it  forms  a  slight  and  obscurely  defined  protrusion  of  the 
hernial  region,  although  there  is  no  actual  external  pro- 
jection of  the  hernial  tumor,  and  this  form  is  known  as 
the  incomplete  inguinal  hernia.  Such  a  hernia  is  not  felt 
until  the  finger  is  introduced  within  the  inguinal  canal. 
If  the  hernia  descends  somewhat  lower,  it  forms  a  small 
tumor  outside  of  the  external  abdominal  ring,  and  this 
form  is  known  as  the  complete  inguinal  hernia.  If  the 
hernia  descends  still  further,  it  follows  the  spermatic  cord, 
and  finally  reaches  the  bottom  of  the  scrotum,  when  it  is 
known  as  a  scrotal  hernia  (Plate  4). 


148  HERNIA. 

PLATE  3. 
A  Congenital  Inguinal  Hernia.— In  this  case  the  hernial  con- 
tents, a  coil  of  intestine,  lie  directly  upon  thfr  testicle,  the  cavity  of 
the  tunica  vaginalis  propria  being  directly  continuous  with  that  of  the 
hernial  sac. 

As  the  scrotal  hernia  increases  in  size,  the  overlying 
integument  becomes  more  and  more  distended.  The  skin 
of  the  scrotum  is  first  involved,  and  finally  that  of  the 
penis  also  covers  the  hernial  tumor.  Figures  41  to  46 
show  the  different  stages  of  development  of  much  scrotal 
hernias. 

In  the  female,  from  what  has  been  said,  the  external 
inguinal  hernia  must  follow  the  course  of  the  round  liga- 
ment, and  consequently  descend  into  the  labium  majus. 
Such  a  hernia  is  known  as  a  labial  hernia  (Fig.  47).  The 
labium  majus  may  become  enormously  distended  by  the 
hernia,  although  these  large  labial  hernias  are  extremely 
rare  as  compared  with  the  relative  frequency  of  large 
scrotal  hernias.  The  reasons  for  the  more  frequent  occur- 
rence of  inguinal  hernia  in  men  than  in  women  have  been 
previously  mentioned. 

A  hydrocele  may  develop  from  the  diverticulum  of  Nuck 
in  the  female,  as  it  does  from  the  corresponding  vaginal 
process  in  the  male,  and  combinations  of  hernia  with 
hydrocele  have  been  observed  which  are  similar  to  those 
seen  in  the  male  in  figures  50  and  51. 

INTERNAL  INGUINAL  HERNIA, 
The  internal   inguinal   hernia  passes   directly  forward 
through  the  internal  inguinal  fossa  (Plate  2  and  Fig.  39) 
and    makes    its   appearance    externally   at   the   external 


7ab..-i. 


\ 


LUh.  AnsL  E  Reidihold,  Miinchen. 


INGUINAL  HERNIA. 


149 


abdominal  ring,  as  does  the  external  inguinal  hernia. 
Since  the  path  taken  by  this  hernia  corresponds  to  no  pre- 
existing canal,  there  are  no  congenital  internal  inguinal 


Fi£.  41. 


Fis.  42. 


Fig.  41. — A  commencing  inguinal  hernia  :  A  protrusion  about  the 
size  of  a  walnut  is  seen  at  the  situation  of  the  left  external  abdominal 
ring. 

Fig.  42. — A  bilateral  external  inguinal  hernia  which  has  stopped  in 
its  descent  at  the  root  of  the  scrotum  and  has  on  both  sides  attained 
the  size  of  a  hen's  egg.  This  patient  also  exhibits  a  small  subperi- 
toneal lii)oma,  which  is  seen  somewhat  to  the  right  of  the  linea  alba 
and  midway  between  the  umbilicus  and  the  xiphoid  process. 


hernias,  and  almost  all  of  the  internal  inguinal  hernias  are 
observed  in  the  later  years  of  life.  We  have  already 
learned  that  the  abdominal  wall  is  particularly  weak  in  the 
region  of  the  internal  inguinal  fossa  (page  29),  and  it  can 


150  HERNIA. 

PLATE  4. 
Acquired  External  Inguinal  Hernia. — In  this  case  the  vaginal 
process  of  the  peritoneum  has  closed  in  a  normal  manner,  so  that  the 
tunica  vaginalis  propria  surrounds  the  testicle  at  the  bottom  of  the 
scrotum  and  a  new  process  of  peritoneum  has  been  protruded  into  the 
scrotum  alongside  of  the  spermatic  cord.  The  cavities  of  the  hernial 
sac  and  of  the  tunica  vaginalis  propria  do  not  communicate,  but  their 
outer  surfaces  lie  in  immediate  contact  with  each  other. 


readily  be  understood  why  this  location  should  be  a  seat 
of  predilection  in  advancing  years  Avhen  the  abdominal 
walls  become  relaxed  and  when  a  chronic  bronchitis  or 
some  similar  cause  may  frequently  augment  tlie  intra- 
abdominal pressure.  It  is  by  no  means  uncommon  for 
these  hernias  (direct)  to  be  bilateral.  Since  the  internal 
(direct)  inguinal  hernia  holds  no  relation  to  the  spermatic 
cord,  it  does  not  follow  the  course  of  the  latter,  and  con- 
sequently does  not  descend  into  the  scrotum  (Fig.  48). 
[The  shape  of  the  direct  inguinal  hernia  is  nearly  always 
globular,  and  this  is  quite  characteristic  of  this  variety. — 
Ed.]  In  very  rare  cases  where  the  internal  (direct)  in- 
guinal hernia  is  particularly  large,  a  scrotal  form  is  some- 
times observed,  but  these  cases  are  marked  exceptions. 


THE  DIAGNOSIS  OF  INGUINAL  HERNIA. 

From  the  points  which  have  been  emphasized  in  the  first 
portion  of  this  work  it  should  be  determined  whether  the 
tumor  in  question  is  a  hernia,  and  then  to  answer  the  fol- 
lowing questions  : 

Why  is  the  hernia  under  discussion  an  inguinal  hernia? 

Is  it  an  external  or  an  internal  inguinal  hernia  ? 


Tab.  4. 


Lith.  Anst  F.  Reichhold,  Miinchen. 


ING  UINA  L  HERNIA . 


151 


With  what  other  affections  eoiild  the  condition  be  con- 
founded ? 

The  first  question  is  easily  answered  if  the  hernia  follows 


:^ps?5; 


\ 


Fig.  43. — Large  left-sided  scrotal  hernia.  The  hernial  tumor  is  not 
sharply  circumscribed,  but  seems  to  gradually  merge  into  the  sur- 
rounding tissues.  Tlie  skin  of  the  penis  has  not  yet  been  utilized  to 
cover  the  hernia.  The  testicle  of  the  right  or  healthy  side  can  be  dis- 
tinctly recognized  at  the  root  of  the  scrotum. 


152 


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Fig.  48. 


INGUINAL  HERNIA.  157 

Fig.  48. — Bilateral  direct  or  internal  hernia  :  The  enlargement  upon 
the  right  side  is  as  large  as  a  man's  fist,  while  that  upon  the  left  has 
attained  the  size  of  a  goose-egg.  In  spite  of  the  considerable  size  of 
the  right-sided  hernia  it  has  not  descended  into  the  scrotum,  and  this 
is  characteristic  of  the  direct  as  compared  with  the  oblique  variety  of 
inguinal  hernia.  The  small  and  non-distended  scrotum  is  seen  below 
the  hernial  swelling. 


the  spermatic  cord  or  is  found  in  the  scrotum,  since  nothing 
but  an  inguinal  hernia  can  take  this  path.  If  the  hernia 
is  of  moderate  size  and  situated  in  the  groin,  the  answer  is 
more  difficult.  It  must  be  borne  in  mind  that  the  hernias 
of  youth,  particularly  in  the  male,  are  almost  without  ex- 
ception inguinal  hernias,  and  that  in  adult  life  femoral 
hernia  is  much  more  common  in  women  than  in  men.  [In 
9600  cases  of  hernia  in  children  under  fourteen  observed 
in  the  Hospital  for  Ruptured  and  Crippled,  60  were 
femoral. — Ed.]  If  the  hernia  is  reducible,  there  is  but 
little  difficulty,  since  the  position  of  the  hernial  orifice  can 
easily  be  determined.  If  the  hernial  orifice  is  above 
Poupai't^s  ligament,  the  hernia  is  inguinal ;  if  it  is  below, 
the  hernia  is  femoral.  If  the  hernia  is  irreducible,  the  de- 
cision as  to  its  variety  may  be  most  difficult,  and  there  are, 
indeed,  cases  in  which  it  cannot  be  determined  with  cer- 
tainty whether  the  hernia  is  inguinal  or  femoral  until  the 
hernial  orifice  has  been  exposed  at  operation  (see  Femoral 
Hernia). 

In  very  large  scrotal  hernias  it  is  not  always  easy  to 
determine  to  which  side  the  hernia  belongs.  In  figure  46 
the  scrotum  has  become  so  much  distended  that  this  ques- 
tion can  only  be  decided  after  careful  examination.  There 
are  two  points  which  serve  as  guides  :  first,  the  side  upon 


158  HERNIA. 

which  the  hernia  passes  into  the  abdominal  cavity ;  and, 
second,  the  location  of  the  testicles.  The  testicle  of  the 
healthy  side  remains  in  its  original  position,  as  shown  in 
figures  43  and  44,  while  upon  the  side  of  the  hernia  the 
testicle  is  usually  pushed  down  to  the  deepest  and  most 
posterior  part  of  the  scrotum  (Fig.  46). 

If  the  hernia  is  not  too  large,  the  course  of  the  hernial 
canal  will  indicate  wliether  the  hernia  is  external  or 
internal.  If  the  hernia  is  external,  the  canal  passes 
upward  and  outward ;  while  if  it  is  internal,  the  canal 
passes  directly  backward  through  the  anterior  abdominal 
Avail.  We  have  already  learned  that  in  small  children  the 
inguinal  canal  passes  directly  through  the  abdominal  wall, 
but  this  is  offset  by  the  fact  that  the  internal  (direct) 
inguinal  hernia  is  an  affection  of  advanced  life,  and  is  but 
rarely  encountered  in  children.  In  adults  the  increasing 
size  of  the  hernia  gradually  dilates  the  inguinal  canal,  and 
finally  causes  it  to  lose  its  oblique  direction.  In  these 
cases,  however,  we  are  aided  by  another  characteristic  to 
which  attention  has  previously  been  called :  while  the 
increasing  size  of  the  external  oblique  inguinal  hernia 
causes  it  to  descend  into  the  scrotum,  the  internal  direct 
inguinal  hernia  usually  stops  at  the  root  of  the  scrotum. 
The  external  inguinal  hernia,  moreover,  is  to  the  outer  side 
of  the  deep  epigastric  artery,  while  the  internal  inguinal 
hernia  is  to  its  inner  side,  and  it  is  consequently  to  be 
assumed  that  by  the  introduction  of  the  finger  into  the 
hernial  canal,  the  relation  of  the  deep  epigastric  artery  to 
the  hernial  orifice  could  be  determined.  As  a  matter  of 
fact,  a  distinct  pulsation  of  this  artery  is  so  rarely  obtained 
that  this  method  of  differentiation  is  often  of  no  value. 


INGUINAL  HERNIA. 


159 


An  inguinal  hernia  could  be  mistaken  for  a  dislocated 
testicle,  for  swollen  lymphatic  glands,  for  a  psoas  abscess, 
for  a  tumor  of  the  testicle,  for  a  subperitoneal  lipoma,  and 
particularly  for  a  hydrocele.     In  making  a  diagnosis  all 


Fig.  49. — A  subperitoneal  lipoma  of  the  inguinal  region.  The 
traction  of  the  lipoma  upon  the  parietal  peritoneum  has  produced  a 
funnel-shaped  hernial  sac.  a,  Hernial  sac  ;  b,  spermatic  cord  ;  c, 
subperitoneal  lipoma. 


of  these  conditions  must  be  borne  in  mind  or  mistakes  of  a 
most  disagreeable  character  may  result.  The  patient  will 
be  anything  but  grateful  to  the  surgeon  who  mistakes  a 
testicle  which  has  descended  only  as  far  as  the  groin  for  a 


160 


HERNIA. 


hernia,  and  who  forcibly  attempts  to  replace  it  within  the 
abdomen,  when  a  glance  at  the  empty  scrotum  upon  the 
affected   side    and    palpation    would    at    once    reveal  the 


v..  ■^.    .  - 

Fig.  50. — Bilateral  hydrocele  of  the  testicle.  The  sharp  definition 
of  the  scrotal  swelling  from  the  abdominal  wall  should  be  noted  as 
compared  with  Figs.  42-46. 


absence  of  the  testicle.  [In  most  cases  of  partially  descended 
testis  there  is  also  a  hernia  above  the  testis. — Ed.]  Sub- 
peritoneal lipomas  occur  much  more  rarely  in  the  inguinal 


ING  UINA  L  HERNIA . 


161 


than  in  the  femoral  region,  but  they  are  occasionally 
observed  (Fig.  49),  and  may  give  rise  to  errors  in  diag- 
nosis. 

It  must  be  remembered  that  hydroceles  are  not  so  very 
rare  in  the  female,  and  it  may  be  said  that  the  differential 
diagnosis  which  must  be  most  frequently  made  is  that 
between  this  condition  and  an  inguinal  hernia.  Some  of 
the  points  of  difference  have  already  been  given  under  the 
general  diagnosis  of  hernia  (page  58),  and  at  this  place  it 
will  be  sufficient  to  tabulate  side  by  side  the  main  features 
of  the  two  conditions. 


Inguinal  Hernia. 


Hydrocele  Testis. 


Anamnesis. 


The  tumor  appears  suddenly  dur- 
ing an  augmentation  of  the 
intra-abdominal  pressure  ; 

or 
gradualh',    in  which  case  the 
swelling  is  first  noticed  in  the 
abdominal   wall   and    the   en- 
largement is  toward  the  testicle. 


The  swelling  develops  more  slow- 
ly, not  rarely  after  a  contusion 
of  the  scrotum  or  inflammatory 
changes  in  the  epididymis. 

The  swelling  commences  in  the 
bottom  of  the  scrotum  and 
gradually  spreads  toward  the 
abdomen. 

With  a  single  exception — hydro- 
cele communicaus — they  do  not 
suddenly  change  in  size. 


Inspection. 


The  swelling  seems  to  be  directly 
continuous  with  the  tissues  of 
the  abdomen  (Fig.  43). 

The  swelling  is  not  translucent ; 
in  rare  cases  in  very  3'oung 
children  it  may  be  translucent. 


11 


The  swelling  is  usually  sharply 
circumscribed  from  the  ab- 
domen (Fig.  50). 

The  swelling  is  translucent  ;  if 
the  walls  are  very  thick,  or  if 
spermatic  fluid  or  blood  is 
present,  it  may  not  be  translu- 
cent. 


162  HERNIA. 

Fig.  51. — a,  An  ordinary  hydrocele  testis.  The  tunica  vaginalis 
propria  is  distended  by  a  collection  of  fluid  ;  the  parietal  peritoneum 
passes  smoothly  over  the  internal  abdominal  ring. 

b,  In  spite  of  the  constriction  of  the  vaginal  process  and  the  for- 
mation of  the  tunica  vaginalis  propria,  the  parietal  peritoneum  has 
not  retracted  into  the  peritoneal  cavity,  but  remains  adherent  to  the 
outer  surface  of  the  tunica  as  a  congenital  hernial  sac — one  of  the 
rarer  forms  of  the  congenital  inguinal  hernia. 

c,  The  walls  of  the  vaginal  process  have  become  adherent  in  several 
situations,  and  this  has  resulted  in  the  formation  of  a  number  of  sacs. 
At  the  bottom  of  the  scrotum  is  a  hydrocele  of  the  testicle,  above  this 
are  two  hydroceles  of  the  spermatic  cord,  and  still  further  upward  the 
hernicl  sac  is  encountered. 

d,  The  bottom  of  the  scrotum  is  filled  by  a  hydrocele  of  the  testicle. 
The  hernial  sac  has  descended  into  the  scrotum  until  it  lies  in  close 
contact  with  the  sac  of  the  hydrocele. 

e,  In  this  case  a  hydrocele  of  the  testicle  has  formed,  and  the  sub- 
sequently descending  hernial  sac  could  only  partly  displace  the  pos- 
terior portion  of  the  sac  of  the  hydrocele,  probably  because  the  hydro- 
cele was  adherent  to  the  anterior  wall  of  the  scrotum.  It  will  be  seen 
that  an  incision  made  anteriorly  would  first  expose  the  hydrocele  and 
then  the  hernia. 

Palpation. 
If  an  attempt  is  made  to  draw       If    the  same   attempt   is    made, 
the  tumor  away  from   the  ab-  nothing    is    felt    between    the 

dominal     wall     between     the  tumor  and  the  abdominal  wall 

thumb  and  index-finger,  a  por-  but  the  constituents  of  the  sper- 

tion  of  the  tumor  is  felt  pass-  matic  cord, 

ing  into  the  abdominal  cavity. 
The  tumor  may  be  replaced.  The  volume  of  the  tumor  remains 

unchanged  ui3on  pressure  (with 
the  exception  of  a  hydrocele 
communicans). 

Percussion. 
Under    certain    circumstances    a      Always  dull  upon  percussion, 
tympanitic  note  is  obtained. 

A  hydrocele  of  the  spermatic  cord  may  also  be  mis- 


Fig.  51. 


163 


164  HERNIA. 

Fig.  52. — f,  The  hernial  sac  in  its  descent  has  invaginated  the  sac 
of  a  previously  formed  hydrocele,  so  that  the  lower  portion  of  the 
hernia  is  surrounded  hy  the  hydrocele.  This  form  is  known  as  an 
encysted  hernia,  and  occurs  in  a  similar  manner  in  connection  with 
the  hydrocele  of  the  cord. 

g,  As  a  result  of  an  incomplete  descent  of  the  testicle  the  obliter- 
ation of  the  vaginal  process  has  failed  to  take  place.  A  hydrocele 
communicans  has  formed,  and  this  has  been  secondarily  converted 
into  a  hernial  sac  by  the  descent  of  a  coil  of  intestine.  This  condition 
is  sometimes  known  as  hydrocele  hernialis. 

h,  This  figure  is  the  counterpart  to  figure  51,  e.  In  this  case  the 
scrotal  hernia  existed  first,  so  that  the  hernial  sac  is  situated  in  front 
of  the  subsequently  formed  hydrocele. 

i  and  k  represent  other  combinations  of  hernia  with  hydrocele  of 
the  cord.  In  i  the  hernia  has  stopped  Just  above  the  hydrocele,  while 
in  k  the  hernia  has  passed  down  in  front  of  the  hydrocele. 


taken  for  an  inguinal  hernia.  On  account  of  the  loose 
connection  between  the  sac  of  this  form  of  hydrocele  and 
the  surrounding  tissues,  the  swelling  can  sometimes  be 
pushed  up  into  the  inguinal  canal. 

The  diagnosis  may  be  quite  difficult  even  during  oper- 
ation, on  account  of  the  simultaneous  occurrence  of  hydro- 
cele and  hernia.  Such  combinations  of  the  most  varied 
character  have  been  observed,  and  they  are  partly  due  to 
anomalies  in  the  closure  of  the  vaginal  process  of  the 
peritoneum.  It  may  happen,  for  example,  that  the  tunica 
vaginalis  propria  is  formed  in  the  normal  manner,  but  that 
the  parietal  peritoneum,  instead  of  retracting  as  usual 
within  the  abdominal  cavity,  has  remained  adherent  at  the 
point  of  constriction  (Fig.  51,  b).  In  such  a  case  an 
anatomic  condition  would  exist  which  we  have  learned  to 
regard  as  typical  of  acquired  inguinal  hernia,  and  yet  the 
sac  would  be  congenital.     The  walls  of  the  vaginal  pro- 


Fig.  52. 


165 


166  HERNIA. 

Fig.  53. — A  sketch  of  a  bilocular  ingiiino-properitoneal  hernia. 

cess  may  become  adherent  in  several  places,  so  that  a 
number  of  sacs  are  formed  which  are  situated  one  above 
the  other.  Figure  51,  c,  shows  such  a  case  in  which  a 
hydrocele  of  the  testicle,  two  hydroceles  of  the  cord,  and 
a  hernial  sac  were  found. 

The  diagrammatic  drawings  in  figures  51  and  52  show 
the  manifold  relations  of  diiferent  hydroceles  to  a  hernia, 
which  may  be  above,  in  front  of,  behind,  or  even  surrounded 
by  the  sac  of  the  hydrocele. 

INTERPARIETAL  INGUINAL  HERNIA  (INTERSTITIAL). 
By  an  interparietal  inguinal  hernia  we  understand  a 
hernia  in  which  that  portion  situated  within  the  abdominal 
wall  pushes  in  between  the  individual  layers  of  the  abdom- 
inal parietes  and  enlarges  in  this  direction.  While  the 
ordinary  inguinal  hernia,  even  when  large  in  size,  simply 
pushes  aside  the  layers  of  the  abdominal  wall  as  it  passes 
through  them,  the  interparietal  hernia  insinuates  itself 
between  two  layers  of  the  abdominal  parietes.  And  if 
strangulation  supervenes  in  such  a  case,  the  same  anatomic 
conditions  are  reproduced  which  exist  after  a  reduction 
en  masse  (Fig.  32).  In  addition  to  the  publication  of  two 
interesting  cases  from  the  clinic  at  Kiel,  Gobell  has 
recently  collected  the  previously  known  facts  in  reference 
to  this  remarkable  form  of  hernia  and  aided  considerably 
in  the  clear  understanding  and  simplification  of  the  nomen- 
clature. Either  the  incomplete  or  the  complete  inguinal 
hernia  may  develop  an  interparietal  diverticulum.  All  these 
forms  of  interparietal  hernia  may  be  either  monolocular  or 


Fig  53. 


INGUINAL  HERNIA.  107 

bilocular ;  i.  c,  the  entire  sac  may  be  situated  between  the 
layers  of  the  abdominal  wall,  or  a  diverticulum  may  extend 
in  this  direction  while  the  remaining  portion  of  the  hernia 
follows  the  spermatic  cord  or  the  round  ligament  and 
descends  into  the  scrotum  or  the  labium  majus  as  the  case 
may  be.  Interparietal  hernia,  like  the  inguinal  variety, 
is  more  common  upon  the  right  than  upon  the  left  side. 

Three  different  forms  of  interparietal  hernia  are  to  be 
differentiated  :  (1)  Properitoneal  inguinal  hernia  (Kronlein) ; 
(2)  interstitial  inguinal  hernia  (Goyrand) ;  (3)  superficial 
inguinal  hernia  (Boyer,  Klister). 

1.  The  properitoneal  inguinal  hernia  {hernia  inguin- 
alis  jjroperitonealis,  or  hernia  inguino-jyrojjeritonealis)  in- 
sinuates itself  between  the  peritoneum  and  the  transversalis 
fascia.  There  are  two  subvarieties  of  this  form  described 
— the  iliac,  in  which  the  protrusion  occurs  toward  the 
iliac  region,  and  the  antevesical,  in  which  it  is  in  front  of 
the  bladder.  According  to  Gobell,  69  positive  instances 
of  this  variety  of  hernia  have  been  observed  up  to  the 
present  time ;  67  were  in  men,  2  in  women.  Only  7  were 
reducible,  the  remainder  were  strangulated,  and  the  great 
majority  were  bilocular. 

2.  In  the  interstitial  inguinal  hernia  {hernia  inguin- 
al'is  inter stitialis)  the  hernial  sac  may  be  :  (1)  Between  the 
transversalis  fascia  and  the  transversalis  muscle ;  (2)  be- 
tween the  fibers  of  the  internal  oblique  muscle  ;  (3)  between 
the  internal  and  external  oblique  muscles  ;  (4)  between  the 
external  oblique  muscle  and  the  transversalis  fascia,  the 
internal  oblique  and  transversalis  muscles  having  been 
pushed  aside. 

The  interstitial  inguinal  hernia  is  bv  far  the  most  fre- 


168  HERNIA. 

PLATE  5. 

A  Right=sided  Strangulated  Bilocular  Iliac  Properitoneal 
Inguinal  Hernia. — From  an  anatomic  specimen  from  the  body  of  a 
female  fifty-nine  years  of  age  (Prof.  Nauwerck,  Chemnitz)  :  a,  Affer- 
ent intestine  ;  b,  efferent  intestine  ;  c,  ligamentum  teres  uteri  ;  d, 
parietal  peritoneum  ;  e,  seat  of  constriction  ;  f,  properitoneal  inguinal 
hernia ;  g,  the  smaller  peripheral  portion  of  the  hernial  sac  ;  h,  Pou- 
part's  ligament  ;  i,  femoral  artery  ;  k,  femoral  vein. 

The  smaller  external  portion  (about  \)  of  the  bilocular  hernial  sac 
is  situated  immediately  above  Poupart's  ligament  ;  the  larger  portion 
(about  I)  has  lifted  up  the  parietal  peritoneum  from  the  transversalis 
fascia  in  the  region  of  the  inguinal  canal,  as  shown  by  the  displaced 
ligamentum  teres,  and  is  located  between  the  parietal  peritoneum  and 
the  transversalis  fascia.  The  hernial  sac  has  been  partially  cut  open, 
exposing  the  dark  red  strangulated  intestinal  coil.  Above  the  seat  of 
constriction  are  seen  the  distended  afferent  and  the  collapsed  efferent 
intestine. 

quent  variety  of  the  interparietal  inguinal  hernias.  Accord- 
ing to  Gobell,  199  cases  have  been  described  up  to  the 
present  time;  162  were  in  men,  37  in  women. 

3.  The  superficial  inguinal  hernia  {hernia  mguinalis 
superjicialis)  is  situated  between  the  aponeurosis  of  the 
external  oblique  muscle  and  the  skin.  All  the  cases  which 
have  been  carefully  examined  were  found  to  be  congenital 
hernias  with  malpositions  of  the  testicle,  and  K lister  pre- 
viously stated  that  this  combination  is  characteristic  of  this 
variety  of  interparietal  hernia.  There  are  only  14  cases 
of  this  form  on  record  at  the  present  time,  and  the  reason 
w^hy  the  number  is  so  small  is  probably  because  this  var- 
iety has  not  impressed  itself  upon  many  as  a  distinct  and 
peculiar  form  of  hernia.  [I  have  just  operated  upon  a 
typical  example  of  this  variety  of  hernia.  The  patient,  a 
boy  aged  ten  years,  had  a  double  inguinal  hernia,  both 
sides  being  the  same  form. — Ed.] 


rah.s. 


Jilh     \r,si  .'-■  RpirJifmlil    Winrh, 


INGUINAL  HERNIA.  169 

lu  the  monolocular  form  of  the  properitoneal  and  inter- 
stitial inguinal  hernia  the  diagnosis  is  made  by  the  pres- 
ence of  a  swelling  in  the  inguinal  region  which  extends 
laterally  beyond  the  location  of  the  inguinal  canal,  and 
which  presents  the  general  symptoms  of  a  hernia.  The 
free  external  abdominal  ring  can  be  palpated,  and  yet  the 
swelling  becomes  more  marked  when  the  patient  strains  or 
coughs.  After  reduction  the  internal  abdominal  ring  also 
may  usually  be  palpated.  In  the  bilocular  form  the  her- 
nial tumor  has  an  hour-glass  shape,  the  constricted  portion 
being  situated  at  the  external  abdominal  ring.  After  the 
reduction  of  the  hernial  contents  situated  external  to  the 
external  abdominal  ring,  the  same  condition  is  present  as 
exists  in  the  monolocular  form.  The  superficial  variety 
behaves  somewhat  differently.  In  contrast  to  what  has 
been  said  of  the  other  forms,  they  fill  up  only  when  the 
external  abdominal  ring  is  open  and  remain  empty  when 
this  ring  is  closed  by  the  finger. 

Almost  all  of  these  diagnostic  points  refer  to  reducible 
interparietal  hernias  ;  if  the  hernia  is  irreducible  or  stran- 
gulated, the  diagnosis  becomes  much  more  difficult  and 
frequently  impossible  until  the  time  of  operation.  These 
hernias  are  to  be  treated  upon  the  same  principles  as  those 
which  apply  in  the  ordinary  forms  of  inguinal  hernia . 

TREATMENT  OF  INGUINAL  HERNIA. 
The  Treatment  by  Means  of  a  Truss. — The  indica- 
tions for  the  treatment  by  means  of  a  truss  and  the  methods 
of  its  manufacture  and  application  have  been  already  given 
in  the  section  upon  hernia  in  general  (page  64).  At  this 
place  it  will  consequently  be  sufficient  to  point  out  the  spe- 


170  HERNIA. 

cial  requirements  of  a  truss  for  an  inguinal  hernia.  In 
spite  of  the  innumerable  highly  praised  jointed,  adjustable, 
and  spring  pads,  the  simple  pad,  covered  as  previously  de- 
scribed and  firndy  connected  with  the  spring  of  the  truss, 
continues  to  be  the  best  of  all  varieties.  The  size  and 
form  of  the  pad  as  well  as  the  strength  and  direction  of  the 
force  exerted  by  the  spring,  however,  must  be  adapted  to 
the  individual  case.  It  is  of  particular  importance  that 
the  pad  should  not  only  close  the  external  abdominal  ring, 
but  that  it  should  also  exert  pressure  upon  the  entire 
inguinal  canal  as  far  up  as  the  internal  abdominal  ring. 
This  end  may  be  best  attained  in  the  majority  of  cases, 
according  to  Graser,  by  a  wedge-shaped  pad,  the  lateral 
thick  portion  being  placed  over  the  internal  abdominal  ring 
and  the  inner  and  thinner  portion  over  the  inguinal  canal. 

In  small  hernias  and  those  which  are  moderate  in  size, 
a  perineal  strap  is  unnecessary  if  the  pad  and  spring  are 
correctly  adjusted,  as  has  previously  been  described  (Fig. 
54,  a  and  b).  In  large  scrotal  hernias,  in  which  the  pad 
should  close  the  canal  as  in  all  other  varieties,  compression 
upon  the  hernial  region  is  best  attained  by  extending  the 
pad  downward  and  adding  a  perineal  strap  (Fig.  54,  c). 
Care  must  be  taken,  however,  that  this  extension  does  not 
press  against  the  pubic  bone,  since  this  would  prevent  the 
pad  from  pressing  upon  the  inguinal  canal. 

In  ordering  a  truss  from  an  instrument-maker  the  fol- 
lowing facts  must  be  stated,  although  it  should  be  particu- 
larly emphasized  that  in  the  great  majority  of  cases  the 
presence  of  a  thoroughly  competent  individual  is  essential 
to  adapt  the  truss  to  the  patient.  Many  a  truss  which  has 
originally  been  regarded  as  useless  may  be  easily  adjusted 


INGUINAL  HERNIA, 


171 


by  a  slight  honding  or  twisting  of  the  s])ring.     Tlie  neces- 
sary facts  for  the  maker  of  the  truss  are  : 
1.   Age,  sex,  and  occupation  of  the  patient. 


Fig.    54,    a. — Single    inguinal 
truss  Avithout  a  j)erineal  strap. 


Fig.  54,  b. — Double   inguinal 
truss  without  a  perineal  strap. 


Fig.  54,  c. — Truss  for  a  scrotal  hernia,  with  a  padded  extension  at  the 
inner  and  lower  portion  of  the  pad  and  with  a  perineal  strap. 


Fig.  54,  d. — The  Pomeroy  truss. 


2.   Is  the  inguinal  hernia  internal  or  external?     Direct 
or  oblique  ?     Right-sided,  left-sided,  or  bilateral  ? 


172  HERNIA. 

3.  How  many  fingers  may  be  comfortably  introduced 
into  the  hernial  orifice  ? 

4.  How  far  has  the  hernia  descended  ?  Into  the  scro- 
tum or  labium  majus  ? 

5.  Is  the  pressure  necessary  to  retain  the  hernia  during 
coughing  strong,  moderate,  or  slight? 

6.  What  is  the  circumference  of  the  pelvis  at  a  point 
midway  between  the  anterior  superior  spine  of  the  ilium 
and  the  great  trochanter?  This  distance  is  measured  by 
placing  the  end  of  the  tape  over  the  center  of  the  hernial 
orifice  and  carrying  the  tape  about  the  body  midway  be- 
tween the  anterior  superior  spine  and  the  great  trochanter 
back  to  the  starting-point. 

The  Radical  Operation  for  Inguinal  Hernias. — 
Although  a  great  many  different  methods  of  performing  the 
radical  operation  have  been  suggested,  the  number  which 
is  actually  employed  at  the  present  day  is  very  small. 
In  fact,  only  two  or  three  methods  need  be  considered  if 
we  disregard  the  large  number  of  operative  procedures 
which  are  merely  more  or  less  justifiable  modifications. 
As  it  is  not  our  purpose  to  enumerate  and  carefully  study 
all  the  methods  recommended,  we  will  limit  ourselves  to 
the  consideration  of  those  of  Bassini  and  Kocher,  since 
they  have  stood  the  test  of  experience  and  are  the  opera- 
tions most  generally  adopted.  Maceweu's  operation,  al- 
though less  frequently  employed,  will  also  be  described, 
since  it  depends  upon  a  different  principle. 

Whether  silk,  catgut,  kangaroo-tendon,  silkworm-gut, 
or  silver  wire  is  chosen  as  the  suture  material  in  the  dif- 
ferent operations  depends  largely  upon  the  habit  of  the 
individual   operator ;  and  as  the  material  selected  has  no 


ING  UINA  L  HERNIA .  l(?j 

great  determining  influence  upon  the  result  ol)tained,  gen- 
eral rules  upon  this  sul)ject  cannot  be  formulated.  [I 
believe  that  the  choice  of  suture  material  is  a  matter  of 
great  importance.  It  has  been  fully  demonstrated  that  in 
a  certain  proportion  of  cases  non-absorbable  sutures  buried 
in  the  hernial  canal  cause  sinuses  to  develop  at  long  inter- 
vals after  operation.  These  sinuses  are  slow  in  healing, 
and  the  prolonged  suppuration  so  weakens  the  canal  that 
a  recurrence  takes  place.  A  large  series  of  such  cases  has 
been  observed  at  the  Hospital  for  Ruptured  and  Crippled, 
and  reported  by  Dr.  Bull  and  myself.  Better  results 
have  been  obtained  by  chromicized  tendon  or  catgut, 
and  I  believe  that  non-absorbable  sutures  should  be 
discarded  in  all  operations  for  the  radical  cure  of  hernia, 
—Ed.] 

Bassini's  Operation. — Bassini  aims,  by  his  operation, 
to  completely  close  the  hernial  canal  within  the  abdominal 
wall, — /.  e.,  the  inguinal  canal, — and  to  form  a  new  canal 
for  the  cord  which  shall  correspond  as  much  as  possible  to 
physiologic  conditions.  His  radical  operation  is  composed 
of  three  steps  : 

First  step :  The  pillars  of  the  external  abdominal  ring 
and  the  aponeurosis  of  the  external  oblique  muscles  are 
exposed  by  an  oblique  incision  corresponding  to  the  course 
of  the  spermatic  cord.  The  aponeurosis  of  the  external 
oblique  muscle  is  now  incised  up  to  a  point  above  the 
location  of  the  iflternal  abdominal  ring,  se^^arated  from 
the  underlying  tissues,  and  the  two  flaps  turned  back  to 
either  side.  The  hernial  sac  is  now  separated  from  the 
spermatic  cord  by  blunt  dissection  and  completely  isolated 
from  the  surrounding  tissues,  particularly  in  the  vicinity 


174  HERNIA. 

Fig.  55. — First  step  of  Bassini's  oi)erati()ii  :  The  cutaneous  inci- 
sion and  the  division  of  tlie  aponeurosis  of  the  external  ol)li(]ue  mus- 
cle over  the  entire  inguinal  canal  have  already  lieen  made  and  tlic 
two  aponeurotic  flaps  reflected  to  either  side.  The  hernial  sac  has 
been  extirpated,  nothing  but  its  stiimp  being  visible  in  tlie  outer 
angle  of  the  wound.  The  spermatic  cord  is  elevated  upon  a  l)lunt 
hook.  The  outer  flap  of  the  aponeurosis  of  the  external  oljlique 
muscle  is  directly  continuous  with  Poupart's  ligament,  which  is 
recognized  by  its  yellowash,  glistening,  and  tendinous  appearance. 
Beneath  the  inner  aponeurotic  flap  is  seen  the  conjoined  tendon  of  the 
internal  oblique  and  transversalis  muscles.  The  external  border  of 
the  rectus  muscle  is  situated  to  the  inner  side  of  the  inner  angle  of  tlie 
wound,  and  is  not  visible  in  the  illustration.  The  sutures  which  are 
to  obliterate  the  inguinal  canal  have  been  introduced  but  not  tied. 

Fig.  56. — Second  step  of  Bassini's  operation  :  The  spermatic  cord 
and  the  retracted  aponeurotic  flaps  are  in  the  same  position  as  shown 
in  the  preceding  figure.  The  entire  inner  edge  of  the  muscular  mass 
has  been  firmly  united  to  Poupart's  ligament,  only  the  lowest  suture 
still  remaining  untied.  In  this  manner  the  posterior  wall  of  the  new 
inguinal  canal  is  formed. 

Fig.  57. — Third  step  of  Bassini's  operation  :  The  posterior  wall  of 
the  new  inguinal  canal  is  now  completely  closed.  The  spermatic  cord 
lies  in  its  new  position.  The  anterior  wall  of  the  new  inguinal  canal 
is  formed  by  the  reunited  aponeurosis  of  the  external  oblique  muscle. 
One  suture  still  remains  untied. 


of  the  neck  of  the  sac,  so  that  every  trace  of  a  funnel-like 
diverticulum  disappears.  After  the  hernial  contents  have 
been  reduced,  the  sac  is  opened  at  some  distance  from  the 
neck,  any  adhesions  between  the  sac  and  contents  sepa- 
rated, the  protruding  portions  of  omentum  ligated  en  masse 
and  extirpated,  and  the  hernial  sac  ligated  as  high  up  as 
possible — preferably  by  the  method  of  double  ligation 
described  upon  page  72.  [If  the  omentum  is  easily 
reducible  and  not  adherent,  we  believe  it  should  seldom  be 


Fig.  55. 


\ 


Funiculus  spermaticus. 

Saccus  herniae  ing-uinalis. 

M.  obliquus  internus  et  transversus. 

Lijj;ainentum  inguinale. 

Aponeurosis  muse,  obliqui  externi. 


Fuj.  50. 


Funiculus  sperniaticus. 

M.  obliquus  internus  et  trausversus. 
Lig-amentum  inguinale. 

Aponeurosis  niusc.  obliqiii   externi. 


Fig.  r,7. 


\ 


Aponeurosis  muse,  obliqui  externi. 


M.  obliquus  internus  e    transversu; 
Funiculus  spermaticus. 


ING  UINA L  HERNIA.  1 7 5 

removed.  AA'hen  removed,  it  should  be  tied  off  in  small 
portions  and  never  ligatured  "  en  masse,"  a  procedure 
which  has  caused  death  in  a  number  of  instances. — Ed.] 
The  sac  is  then  cut  oif  one  centimeter  below  the  ligature 
and  the  stump  is  buried  in  the  abdominal  cavity. 

Second  step :  The  isolated  spermatic  cord  is  lifted  up 
and  held  to  one  side.  The  two  flaps  of  the  aponeurosis 
of  the  external  oblique  muscle  are  held  back  by  retractors, 
and  the  whole  mass  of  muscle  situated  internally — the 
larger  upper  portion,  composed  of  the  internal  oblique 
and  transversalis  muscles,  the  smaller  lower  portion,  com- 
posed of  the  rectus  muscle — is  united  throughout  its  entire 
extent  with  Poupart's  ligament  by  four  or  five  interrupted 
sutures,  so  that  only  a  sufficient  opening  for  the  spermatic 
cord  is  left  in  the  upper  and  outer  angle  of  the  wound 
(Figs.  55  and  6Q). 

TJiird  step :  The  spermatic  cord  is  laid  upon  the  new^ly 
formed  posterior  wall  of  the  inguinal  canal,  and  the  two 
flaps  of  the  aponeurosis  of  the  external  oblique  muscle  are 
sutured  over  it,  thus  forming  the  anterior  wall  of  the  new 
inguinal  canal. 

The  operation  is  concluded  by  the  suture  of  the  cuta- 
neous wound. 

Kocher's  Operation. — Kocher  wishes  to  avoid  the 
splitting  up  of  the  inguinal  canal  which  must  be  made  in 
Bassini's  operation  and  performs  an  operation  which  he 
designates  as  the  lateral  displacement  method,  and  which 
may  be  divided  into  four  steps. 

First  step  (Fig.  58)  :  The  skin  is  incised  in  the  direc- 
tion of  the  inguinal  canal,  the  length  of  the  incision  being 
somewdiat  greater  than  that  of  the  canal.     The  incision  is 


17() 


HERNIA. 


not  to  be  carried  down  any  further  than  is  necessary  for  the 
isolation  of  the  hernial  sac  from  the  spermatic  cord  and  the 
separation  of  the  sac  from  the  surrounding  tissues.     An 


•  Aponeurosis  muse, 
obliqui  externi 


-Saccus  hernise 

inguinalis 
■Funiculus  sper- 
maticus 


Fig.  58. — First  step  of  Kocher's  operation. 


incision  at  right  angles  to  the  course  of  the  inguinal  canal 
is  now  made  somewhat  to  the  outer  side  of  the  region  of 
the  internal  abdominal  ring.  (From  an  oversight,  the 
lateral  situation  of  this  incision  in  the  illustration  has  not 


INGUINAL  HERNIA. 


Ill 


been  made  sufficiently  distinct.)  The  hernial  sac  is  isolated 
and  its  contents  reduced  as  in  the  first  step  of  Bassini's 
operation. 


Aponeurosis   muse, 
obliqui  externi. 


-Saccus   hernise    in- 
guinalis. 


Fig.  59.— Second  step  of  Kocher's  operation. 


Second  step  (Fig.  59)  :  A  curved  dressing-forceps  is  now 
introduced  into  this  lateral  opening,  carried  through  the 
inguinal  canal,  brought  out  at  the  external  abdominal  ring 
1^ 


178 


HERNIA. 


in  front  of  the  sjiermatic  cord,  and  made  to  grasp  the  tip 
of  the  isolated  hernial  sac. 

Third  step  (Fig.  60)  :  The  entire  hernial  sac  is  drawn 


—  Aponeurosis 

muse,  obliqiii 
extern  i. 


— Funiculus 

spermaticus. 


Fig.  60. — Third  step  of  Kocher's  operation. 


INGUINAL  HERNIA. 


170 


back  through  the  inguinal  canal  and  out  through  the  small 
lateml  opening.  The  sac,  instead  of  passing  inward  and 
downward,  now  runs  in  the  opposite  direction,  and  the 
funnel-like  neck  of  the  sac  is  forcibly  drawn  into  the  small 


Y 


Aponeurosis  muse. 

obliqui  externi. 


•Funiculus  spermati- 
cus. 


Fig.  61. — Fourth  step  of  Kocher's  operation. 


opening  in  the  external  oblique  muscle.  A  suture  is  now 
passed  around  the  portion  of  the  sac  situated  wdthin  the 
abdominal  wall  and  firmly  tied. 

Fourth  step  (Fig.  61) :  The  neck  of  the  sac  is  still  more 


180  HERNIA. 

securely  fixed  by  a  second  and  sometimes  a  third  suture 
which  passes  more  superficially  through  the  approximated 
fibers  of  the  aponeurosis  of  the  external  oblique  and 
through  a  portion  of  the  neck  of  the  sac.  The  sac  is  then 
cut  off  beyond  these  sutures  and  a  row  of  deep  sutures  is 
passed  through  the  aponeurosis  of  the  external  oblique 
muscle  and  the  underlying  muscular  tissue  in  order  to 
narrow  the  inguinal  canal  throughout  its  entire  extent. 
The  operation  is  completed  by  the  suture  of  the  cutaneous 
incision. 

Kocher  has  obtained  still  better  results  by  a  modifica- 
tion of  this  operation  which  he  has  recently  published, 
and  which  he  designates  as  the  invagination  displacement 
method.  The  first  step  of  the  operation  is  carried  out  as 
in  the  original  method.  In  the  second  step,  however,  not 
only  the  aponeurosis  of  the  external  oblique  muscle  is  in- 
cised, but  the  fibers  of  the  internal  oblique  and  transver- 
salis  muscle  are  also  divided  upon  a  grooved  director  and 
the  peritoneal  cavity  is  opened  in  the  depth  of  the  w^ound. 
The  dressing-forceps  is  introduced  into  the  peritoneal  cav- 
ity through  this  opening,  carried  into  the  interior  of  the 
hernial  sac,  the  apex  of  which  is  seized,  and  the  sac,  instead 
of  being  drawn  back  through  the  inguinal  canal,  is  invag- 
inated  throughout  its  entire  length  and  pulled  out  through 
the  small  lateral  wound.  The  parietal  peritoneum  is  also 
drawn  out  of  the  wound  by  means  of  two  or  four  hemo- 
stats  and  the  sac  is  tied  off  as  high  up  as  possible  by  the 
method  of  double  ligation  previously  described.  The 
operation  is  completed  as  in  the  lateral  displacement 
method. 

Macewen's  Operation. — Macewen  attempts  to  firmly 


I 


Fijr.  62. 


Fig.  64. 


Fig.  63. 

Figs.  62,  63,  64. — Kadical  operation  of  Macewen,  I. 

181 


182  HERNIA. 

close  the  hernial  orifice  by  plugging  it  witli  the  sac,  wliicli 
he  stitches  into  a  pad  and  places  behind  the  internal  ab- 
dominal ring. 

First  step  (Fig.  62) :  Cutaneous  incision  in  the  course 
of  the  inguinal  canal,  isolation  of  the  hernial  sac,  and 
reduction  of  its  contents  as  in  other  operations. 

While  the  empty  hernial  sac  is  drawn  down,  the  oper- 
ator introduces  his  index-finger  in  the  inguinal  canal  and 
separates  the  neck  of  the  sac  from  the  walls  of  the  canal  and 
from  the  spermatic  cord.  The  parietal  peritoneum  is  also 
separated  from  the  abdominal  wall,  by  means  of  the  finger, 
for  a  distance  of  about  1 J  cm.  from  the  internal  abdominal 
ring. 

Second  step  (Fig.  63)  :  As  shown  in  figure  64,  the  sac 
is  stitched  into  a  pad  with  a  long  catgut  suture  which  is 
introduced  through  the  fundus  of  the  sac  and  then  carried 
through  the  entire  length  of  the  sac  up  to  the  external 
abdominal  ring  by  what  might  be  termed  a  longitudinal 
purse-string  suture.  The  free  end  of  this  suture  is  threaded 
into  a  needle  resembling  Deschamps'  aneurysm  needle, 
which  is  then  passed  through  the  inguinal  canal  to  the 
abdominal  side  of  the  anterior  abdominal  wall.  The 
suture  is  now  passed  through  the  abdominal  wall  from 
within  outward  at  a  point  about  3  cm.  above  the  upper 
margin  of  the  internal  abdominal  ring.  By  traction  upon 
the  suture  and  digital  pressure  from  below,  the  sutured  sac 
which  has  been  converted  into  a  pad  is  placed  behind  the 
internal  abdominal  ring.  The  end  of  the  suture  is  fixed 
either  by  passing  it  repeatedly  through  the  musculature  of 
the  abdominal  wall,  or  by  tying  it  to  the  subsequent  cuta- 
neous suture. 


Fig.  66. 
Figs  65,  66,  67.— Radical  operatiou  of  Macewen,  II. 

183 


184  HERNIA. 

Third  step :  The  inguinal  canal  is  now  closed  by  a  mat- 
tress suture.  The  free  end  of  a  strong  catgut  suture  is 
first  passed  from  within  outward  through  the  inner  wall 
of  the  inguinal  canal  by  the  same  needle  that  has  previ- 
ously been  employed. 

Figure  (SQ>  shows  the  completed  mattress  suture,  the  ends 
of  which  have  also  been  passed  through  the  outer  wall  of 
tlie  inguinal  canal  and  now  are  ready  to  be  tied.  If  the 
inguinal  canal  is  very  much  dilated,  a  second  mattress 
suture  may  be  introduced.  In  passing  these  sutures  par- 
ticular care  must  be  taken  to  avoid  including  the  spermatic 
cord.  Figure  67  diagrammatically  indicates  the  cushion- 
like covering  of  the  internal  abdominal  ring. 

The  radical  operation  of  the  external  inguinal  hernia  in 
the  female  is  easier,  since  there  is  no  spermatic  cord  and 
the  entire  inguinal  canal  may  consequently  be  completely 
closed  by  the  sutures.  In  all  cases  care  must  be  taken 
that  the  round  ligament  is  not  divided,  since  such  an 
event  could  be  followed  by  disturbances  of  fixation  of  the 
uterus. 

[The  operation  for  the  radical  cure  of  inguinal  hernia 
in  the  female  gives  by  far  the  best  results  of  all  varieties 
of  hernia. 

Up  to  February,  1902,  I  have  operated  upon  165  cases 
of  inguinal  hernia  in  the  female,  and  although  the  cases 
have  been  very  carefully  traced,  not  a  single  relapse  has 
thus  far  been  observed.  The  method  whicli  I  have  em- 
ployed is  practically  the  same  as  Bassini's  method  in  the 
male.  The  sac  is  always  carefully  dissected  from  the 
round  ligament  and  removed  high  up  on  a  level  with  the 
general  peritoneal  cavity.     The  round  ligament  is  allowed 


FEMORAL  HERNIA.  185 

to  drop  back  into  the  lower  angle  of  the  wound  and  is 
never  transplanted,  as  advised  by  Kelly  and  others  at  the 
Johns  Hopkins  Hospital.  The  internal  oblique  is  sutured 
to  Poupart's  ligament  by  interrupted  sutures  of  kangaroo- 
tendon  and  the  aponeurotic  layer  closed  by  a  continuous 
suture  of  the  same  material ;  the  skin  wound  is  closed  w^ith 
catgut.  The  dressing  is  held  in  place  by  a  firmly  applied 
spica  bandage.  I  have  allow^ed  these  patients  to  sit  up  at 
the  end  of  ten  days,  and  to  leave  the  hospital,  in  most 
cases,  at  the  end  of  tw^o  weeks. 

All  of  my  cases  with  the  exception  of  13  have  been 
traced  and  no  relapse  has  been  seen.  This  would  seem 
sufficient  evidence  to  prove  that  the  method  is  satisfac- 
tory.— Ed.] 

The  radical  operation  of  an  internal  inguinal  hernia  is 
performed  in  a  similar  manner.  Since  the  spermatic  cord 
is  situated  external  to  and  outside  of  the  region  of  the  her- 
nial orifice,  its  treatment  does  not  enter  into  the  question, 
and,  after  the  usual  ligation  and  extirpation  of  the  sac,  the 
hernial  orifice  may  be  completely  closed  by  suture.  In 
some  cases  the  ligation  of  the  deep  epigastric  vessels 
cannot  be  avoided. 


FEMORAL  HERNIA* 

Femoral  or  crural  hernia  is  far  more  infrequent  in  the 
male  than  is  the  inguinal  variety,  and  it  is  also  much  more 
rarely  observed  in  the  male  than  in  the  female.  Accord- 
ing to  the  calculation  of  Berger,  only  5.6  ^  of  all  males 
with  hernias  have  the  femoral  variety,  the  corresponding 
percentage  among  females  being  32.7^.     If  this  latter 


186  HERNIA. 

percentage  is  compared  with  that  of  the  inguinal  variety 
in  all  hernias  of  the  female, — 44.3^, — it  will  be  seen 
that  the  inguinal  hernias  are  also  more  common  in  the 
female  than  are  femoral  hernias. 

ANATOMY. 

If  we  briefly  review  what  has  already  been  said  of  the 
anatomy  of  the  anterior  femoral  region  in  the  general  con- 
sideration of  the  hernial  orifices,  we  see  (Fig.  2)  that  the 
superficial  fascia  below  the  inner  third  of  Poupart's  liga- 
ment exhibits  a  number  of  sieve-like  perforations.  This 
portion  of  the  superficial  fascia  is  known  as  the  cribriform 
fascia,  and  gives  passage  to  the  great  saphenous  vein  as  it 
passes  from  the  inner  side  of  the  thigh  to  empty  into  the 
femoral  vein.  After  the  removal  of  the  superficial  fascia 
(Fig.  3)  the  fascia  lata  is  exposed,  the  sharp  concave  falci- 
form process  of  which  forms  the  outer  border  of  the  saphe- 
nous opening.  This  opening  is  situated  just  beneath  the 
cribriform  fascia,  and  through  its  inner  portion  may  be 
seen  the  femoral  vessels  inclosed  in  a  common  sheath. 
The  femoral  vein  lies  to  the  inner,  the  femoral  artery  to 
the  outer  side,  only  a  narrow  edge  of  the  latter  being  visi- 
ble. To  the  inner  side  of  the  vein  there  is  almost  always 
a  lymphatic  gland,  which  is  known  as  the  gland  of  Rosen- 
miiller  (Fig.  4),  and  it  is  in  this  situation  that  the  femoral 
hernia  makes  its  external  appearance.  To  thoroughly 
understand  the  course  taken  by  this  hernia,  however,  we 
must  first  direct  our  attention  to  the  bony  and  ligamentous 
framework  which  forms  the  foundation  of  its  place  of  exit 
(Fig.  68).  The  bony  arch  situated  between  the  anterior 
superior  spine  of  the  ilium  and  the  spine  of  the  pubis  has 


FEMORAL  HERNIA. 


187 


its  concavity  directed  upward  and  is  bridged  over  l)y  Pou- 
part's  ligament.  The  space  between  the  ligament  and  the 
bone  is  divided  into  two  halves  by  the  iliopectineal  fascia, 
which  branches  off  from  about  the  middle  of  Poupart's 
ligament  and  is  inserted  into  the  iliopectineal  eminence. 


Fig.  68. — Bony  pelvis  showing  the  muscular  and  vascular  spaces 
formed  by  Poupart's  ligament  and  the  iliopectineal  fascia  :  a,  Muscu- 
lar space  {lacuna  musculorum)  ;  b,  Poupart's  ligament  ;  c,  vascular 
space  {lacuna  vasorum)  ;  d,  Gimbernat's  ligament. 


The  outer  half  is  completely  filled  by  the  iliopsoas  muscle, 
and  is  known  as  the  muscular  space  {lacuna  musculorum)  ; 
the  inner  half  gives  passage  to  the  femoral  vessels,  and  is 
known  as  the  vascular  space  (lacuna  vasorum).  The  angle 
which  Poupart's  ligament  forms  with  the  horizontal  ramus 


188  HERNIA. 

Fig.  60. — Oblique  section  through  the  pelvis  from  the  anterior 
superior  spine  of  the  ilium  to  the  iliopectineal  eminence  :  a,  Anterior 
superior  spine  of  the  ilium  ;  b,  iliopsoas  muscle  ;  the  place  of  approxi- 
mation of  the  iliac  with  the  psoas  muscle  in  which  lies  the  anterior 
crural  nerve  is  recognized  by  a  narrow  edge  of  connective  tissue  ;  c, 
Poupart's  ligament  ;  d,  anterior  crural  nerve  ;  e,  femoral  artery  ;  f, 
femoral  vein  ;  g,  lymphatic  gland  of  Rosenmiiller  ;  h,  Gimbernat's 
ligament ;  i,  spermatic  cord  (or  ligamentum  teres  uteri,  as  the  case 
may  be). 

Fig.  70. — A  right-sided  femoral  hernia,  seen  from  within.  The 
right  anterior  pelvic  wall  is  seen,  together  with  a  portion  of  the 
anterior  abdominal  wall — the  right  rectus  muscle,  and  a  part  of  the 
right  sacrum.  The  peritoneum  has  been  removed  with  the  exception 
of  that  surrounding  the  mouth  of  the  hernial  sac.  The  hernial  sac 
itself  lies  close  to  the  inner  side  of  the  external  iliac  vein  :  a,  Deep 
epigastric  artery  ;  1),  rectus  abdominis  muscle  ;  c,  parietal  peritoneum  ; 
d,  the  mouth  of  a  femoral  hernia  ;  e,  pubic  symphysis  ;  f,  external 
iliao  artery  ;  g,  external  iliac  vein. 


of  the  pubis  is  filled  by  a  small  arched  ligament — Gimber- 
nat's ligament. 

In  a  section  passing  through  the  pelvis  from  the  ante- 
rior superior  spine  of  the  ilium  to  the  iliopectineal  emi- 
nence (Fig.  69)  may  be  seen  the  structures  passing  through 
the  spaces  which  have  just  been  described.  The  place  of 
exit  of  femoral  hernia  is  to  the  inner  side  of  the  femoral 
vein,  where  the  lymphatic  gland  of  Rosenmiiller  is  situ- 
ated in  the  illustration. 

In  order  to  see  the  place  from  which  the  peritoneal  pro- 
trusion occurs  we  must  look  at  the  inner  side  of  the  ante- 
rior abdominal  wall  (Fig.  39).  The  peritoneum  has  been 
removed  in  the  vicinity  of  the  femoral  vessels  and  a  num- 
ber of  perforations  are  seen  in  the  underlying  transversalis 
fascia,  particularly  at  the  point  of  exit  of  the  external  iliac 


Fig.  09. 


FUj.  /(). 


-g- 


FEMORAL  HERNIA.  189 

artery.  Following  the  suggestion  of  Cloquet,  the  portion 
of  the  transversalis  fascia  to  the  inner  side  of  the  external 
iliac  vein  is  known  as  the  septum  crurale.  The  comple- 
ment to  this  picture  is  found  in  figure  70,  which  represents 
a  femoral  hernia  seen  from  within. 

The  path  which  the  femoral  hernia  takes  from  the  mouth 
of  the  sac  to  the  saphenous  opening  is  called  the  femoral 
canal,  although  a  pre-existing  canal,  like  the  inguinal  canal, 
for  example,  does  not  exist.  The  descending  hernia  must 
make  its  own  canal  by  protruding  the  different  fascias  and 
pushing  aside  the  lymphatic  glands  and  loose  areolar  tissue 
which  normally  fill  up  the  space.  After  the  hernia  has 
descended  in  this  manner  it  appears  externally  as  shown 
in  Plate  6. 

From  the  preceding  statements  it  follows  that  the  her- 
nial coverings  are  rather  thin,  consisting  only  of  the  por- 
tion of  transversalis  fascia  designated  as  the  septum  cru- 
rale and  of  the  cribriform  fascia,  which  is  occasionally 
somewdiat  reinforced  by  the  loose  areolar  tissue  situated 
beside  the  vein.  Although  the  hernial  coverings  are  some- 
times thickened  by  inflammatory  changes,  they  are  fre- 
quently so  thin  that  they  can  scarcely  be  recognized  as 
such,  and  the  isolation  of  their  individual  constituents  is 
altogether  out  of  the  question.  In  operating  upon  femoral 
hernias,  particularly  in  patients  in  whom  the  cutaneous 
covering  is  thinned  and  relaxed,  the  surgeon  must  conse- 
quently be  prepared  to  encounter  the  hernial  sac  immedi- 
ately underneath  the  skin. 

It  has  previously  been  repeatedly  emphasized  that  the 
subperitoneal  areolar  tissue  is  particularly  w^ell  developed 
in  the  femoral  region,  often  giving  rise  to  the  formation 


190  HERNIA. 

PLATE  6. 
A  Right=>sided  Strangulated  Femoral  Hernia.— a,  Efferent 
intestine  ;  b,  iliopsoas  muscle  ;  c,  afferent  intestine  ;  d,  Poupart's 
ligament ;  e,  anterior  crural  nerve  ;  f,  femoral  artery  ;  g,  femoral 
vein  ;  h,  spermatic  cord  ;  i,  femoral  hernia  ;  k,  sartorius  muscle  ; 
1,  pectineus  muscle  ;  m,  adductor  longus  muscle.  The  hernial  sac 
protrudes  along  the  inner  side  of  the  femoral  vein,  outside  of  the 
sheath  of  the  vessels.  The  anterior  wall  of  the  sac  has  been  removed, 
exposing  a  dark  red,  cyanotic  intestinal  coil. 

of  subperitoneal  lipomas,  and  their  frequent  occurrence  in 
this  situation  furnished  Roser  with  an  argument  for  the 
development  of  the  hernia  from  the  traction  produced  by 
the  pedicle  of  such  a  tumor. 


THE  DIAGNOSIS  OF  FEMORAL  HERNL\» 
If  the  general  symptoms  of  hernia  and  the  anatomy  of 
the  region  involved  are  borne  in  mind,  the  diagnosis  of 
femoral  hernia  will  not  be  difficult  in  the  majority  of  cases. 
The  differentiation  of  a  femoral  from  an  inguinal  hernia, 
which  has  already  been  briefly  given  in  the  diagnosis  of 
inguinal  hernia,  will  almost  always  be  easy  if  the  course 
of  Poupart's  ligament  is  observed.  When  the  position  of 
the  neck  of  the  hernia  has  been  defined,  and  when  the 
pubic  spine  has  been  palpated  and  connected  with  the  ante- 
rior superior  spine  of  the  ilium  by  an  imaginary  line,  the 
variety  of  the  hernia  may  readily  be  determined,  since  a 
hernia  below  this  line  will  be  femoral,  while  one  above  it 
will  be  inguinal.  This  is  specially  true  of  hernias  of 
moderate  size  in  the  inner  half  of  the  groin,  in  which  it 
cannot  be  seen  at  a  glance  whether  the  hernia  is  inguinal 
or  femoral  (Fig.  71).     Inspection  is  particularly  deceptive 


7\,L  f: 


rn 


LUh.Arist  F.  ReidUwid.  Sfimchen 


FEMORAL  HERNIA. 


191 


if  the  femoral  hernia  extends  upward,  as  it  enlarges  and 
assumes  a  position  in  front  of  Poupart's  ligament.     The 


Fig.  71. — A  right-sided  reducible  femoral  hernia,  about  the  size  of 
a  hen's  egg,  which  has  extended  upward  so  that  it  is  situated  in  the 
inner  third  of  the  inguinal  region.  The  decision  as  to  whether  this 
hernia  is  inguinal  or  femoral  cannot  be  made  at  first  glance,  and  is 
only  possible  after  an  exact  determination  of  the  course  of  Poupart's 
ligament,     Kadical  operation.     Eecovery. 


Fig.  72. — A  right-sided  femoral   hernia,  larger  than  a  man's -fist, 
which  could  be  completely  reduced  and  well  retained  by  a  truss.    The 
hernia  is  situated  in  the  upper  and  inner  portion  of  the  femoral  region 
and  has  pushed  the  labium  majus  toward  the  median  line. 
192 


FEMORAL  HERNIA. 


193 


diagnosis  becomes  more  difficult  in  fat  individuals  with 
pendulous  abdomens,  in  whom  the  position  of  Poupart's 
ligament  cannot  be  determined  either  by  direct  palpation 


Fig.  73. — A  right-sided  irreducible  femoral  hernia  which  contained 
nothing  but  a  thick  mass  of  omentum.    Radical  operation.    Recovery. 
13 


194  HERNIA. 

Fig.  74. — A  bilateral  femoral  hernia  in  a  woman  seventy-five  years 
of  age. 

The  right-sided  hernia,  about  the  size  of  a  child's  head,  was  strangu- 
lated. Its  shape  was  very  irregular  and  the  contours  of  the  individual 
intestinal  coils  could  be  distinctly  recognized  through  the  greatly 
relaxed  and  withered  skin.  The  contents  consisted  of  the  cecum  and 
of  a  convolution  of  intestinal  coils  which  were  matted  together  by 
adhesions.  Herniotomy.  The  reduction  of  the  hernia  was  impossible 
until  after  the  incision  had  been  extended  upward  through  the  ab- 
dominal wall.     Eecovery. 

The  left-sided  hernia,  situated  in  the  upper  and  inner  portion  of  the 
femoral  region,  shows  the  same  tendency  to  irregular  protrusion  as 
that  observed  upon  the  right,  the  skin  being  drawn  in  over  the  middle 
of  the  hernia.  The  contents  could  be  returned  to  the  abdominal 
cavity,  a  gurgling  murmur  being  heard  at  the  time  of  reduction  ;  one 
finger  could  be  comfortably  introduced  into  the  hernial  orifice.  The 
swelling  immediately  below  the  center  of  Poupart's  ligament  was 
caused  by  an  enlarged  lymphatic  gland.  The  irregular  shape  of  both 
hernias  was  probably  due  to  the  fact  that  the  cribriform  fascia  was  not 
pushed  in  front  of  the  hernia  as  a  whole,  but  that  the  hernial  sac  pro- 
truded externally  through  a  number  of  openings  in  the  fascia. 


or  by  the  line  connecting  the  anterior  superior  spine  of  the 
ilium  with  the  spine  of  the  pubis.  If  a  hernia  possessed 
by  such  an  individual  becomes  irreducible  or  strangulated, 
it  will  readily  be  seen  that  the  diagnostic  difficulties  are 
greatly  increased.  The  presence  of  cysts  and  their  com- 
binations with  femoral  hernias  obscure  the  diagnosis  much 
more  rarely  than  is  the  case  in  the  inguinal  region.  As 
there  is  no  structure  analogous  to  the  vaginal  process  in 
this  situation,  such  cysts  are  always  due  to  constrictions 
and  sequestrations  of  portions  of  the  hernial  sac. 

Femoral  hernias  are  usually  of  moderate  dimensions ; 
they  rarely  attain  the  size  of  a  man's  fist,  although  they 
have  been  observed  extending  as  low  down  as  the  knee. 


Fig.  74. 


195 


196  HERNIA. 

Among  the  affections  which  miglit  be  confused  with 
femoral  hernias  should  be  mentioned  subperitoneal  lipomas 
(see  page  47),  swollen  lymphatic  glands,  psoas  abscesses,  and 
the  enlargements  in  the  femoral  region  produced  by  vari- 
cose veins.  This  latter  condition  in  particular  may  closely 
simulate  a  femoral  hernia.  The  varicosity  varies  in  size 
from  that  of  a  hazelnut  to  that  of  a  goose-egg,  and  corre- 
sponds exactly  to  the  situation  in  which  femoral  hernia 
appears,  since  it  is  located  at  the  junction  of  the  internal 
saphenous  with  the  femoral  vein  (Fig.  75).  Since  the 
swelling  disappears  under  slight  compression  and  becomes 
somewhat  more  tense  when  the  intra-abdominal  pressure 
is  markedly  increased,  an  inexperienced  observer  could 
easily  mistake  it  for  a  femoral  hernia.  The  diagnosis  can 
always  be  made,  however,  by  attention  to  the  following 
points  :  When  the  tumor  has  disappeared  under  pressure,  it 
returns  immediately  after  the  removal  of  the  finger,  and  a 
humming  murmur  is  heard,  whioh  is  still  more  distinct 
when  a  stethoscope  is  placed  over  the  part ;  inspection  of 
the  legs  will  always  reveal  extensive  varicosities  of  the 
veins  in  this  situation.  [The  peculiar  thrill  which  is  path- 
ognomonic of  femoral  varix  is  greatly  emphasized  by  hav- 
ing the  patient  cough  while  the  fingers  are  lightly  pressing 
upon  the  swelling. — Ed.] 

In  addition  to  the  typical  femoral  hernia  which  has  just 
been  described  there  are  several  other  varieties.  Figure  76 
shows  a  specimen  belonging  to  the  Pathologic  Institute  of 
Gottingen  in  which  there  are  two  peritoneal  diverticula 
l^dng  side  by  side  in  the  usual  location  of  a  femoral  hernia. 
Similar  double  hernias  have  also  been  observed  in  other 
hernial  regions  (umbilical  region,  Froriep). 

In  some  cases  the  femoral  hernia  mav  leave  the  abdom- 


Fig.  75.— A  swelling,  the  size  of  a  walnut,  in  the  right  groin  due 
to  a  varicosity  ;  marked  varicosities  in  both  legs,  particularly  upon 
the  right  side.  "^      ^ 


197 


198  HERNIA. 

Fig  76. — Double  femoral  hernia,  seen  from  within  :  a,  Parietal 
peritoneum  ;  b,  deep  epigastric  artery  ;  c,  external  iliac  artery  ;  d, 
external  iliac  vein  ;  e,  the  orifices  of  both  hernial  sacs  ;  a  small  strand 
of  omentum  passes  into  the  inner  hernial  sac  ;  f,  obturator  artery  ;  g, 
omentum  ;  h,  symphysis  pubis.  The  greater  portion  of  the  parietal 
peritoneum  has  been  removed,  particularly  behind  the  mouths  of  the 
sacs,  where  only  a  narrow  margin  has  been  left.  This  specimen  also 
shows  an  anomaly  of  the  obturator  artery  which  arises  from  a  short 
trunk  in  common  with  the  deep  epigastric  artery. 


inal  cavity  at  the  usual  situation  and  then  pursue  an  ab- 
normal course,  passing  through  an  opening  in  the  pectineal 
fascia  and  enlarging  either  between  the  pectineus  muscle 
and  its  fascia  or  between  the  fibers  of  the  muscle  (Cloquet, 
B.  Schmidt,  and  others). 

At  this  place  should  be  mentioned  the  properitoneal 
femoral  hernia  (hernia  cruro-properitonealis) ,  which  is  an- 
alogous to  the  properitoneal  inguinal  variety.  This  form 
is  much  rarer  than  the  properitoneal  inguinal  hernia;  in 
the  great  majority  of  cases  it  is  bilocular,  and  occurs  mostly 
in  women. 

In  still  other  cases  the  femoral  hernia  leaves  the  abdom- 
inal cavity  by  an  atypical  route.  It  may  pass  through  an 
opening  in  Gimbernat's  ligament;  such  a  variety  was  first 
described  by  Laugier,  and  subsequent  cases  were  reported 
by  Cruveilhier  and  others.  Another  form,  usuall}^  de- 
scribed under  the  name  of  external  femoral  hernia  (hernia 
cruralis  externa),  was  first  described  by  Hesselbach.  The 
nomenclature  of  this  variety  is  inexact,  since  some  authori- 
ties (Hesselbach)  apply  the  name  to  hernias  which  pass  out 
through  the  muscular  space  (lacuna  musculorum),  while 
others  so  designate  all  hernias  situated  to  the  outer  side  of 
the  femoral  vessels,  and  consequently  include  some  of 
those  which  are  found  within  the  vascular  space  (lacuna 
vasorum).  Still  other  authors  (Linhart)  classify  femoral 
hernias  according  to  their  relation  to  the  deep  epigastric 
artery,  and  call  all  hernias  to  the  outer  side  of  this  vessel 
external  femoral  hernias.  Such  a  nomenclature  would  con- 
sequently include  those  hernias  which  leave  the  abdominal 


Fig.  76. 


FEMORAL  HERNIA.  199 

cavity  to  the  outer  side  of  the  deep  epigastric  artery,  ])ut 
which  come  down  in  front  of  the  femoral  vessels,  instead 
of  to  the  inner  side,  and  which  push  the  femoral  sheath 
before  them  as  they  descend  {Jiernia  cruralis  pravascularis). 
The  development  of  such  hernias  after  traumatism  has  been 
recently  pointed  out  by  Narath,  who  saw  them  arise  after 
the  reduction  of  congenital  dislocations  of  the  hip.  Bahr 
has  also  seen  external  femoral  hernias  (according  to  Hessel- 
bach's  classification)  develop  after  traumatism. 


THE  STRANGULATION  OF  FEMORAL  HERMAS» 

Although  what  has  been  said  of  strangulation  in  general 
applies  to  this  variety  of  hernia,  there  are  many  features 
characteristic  of  strangulated  femoral  hernia  which  deserve 
particular  mention.  In  the  first  place,  femoral  hernias  are 
frequently  very  small  and  may  be  easily  overlooked.  It 
consequently  follows  that  the  femoral  region  should  be 
most  carefully  examined  in  every  case  which  presents  the 
general  symptoms  or  signs  of  intestinal  occlusion.  If  such 
a  course  is  pursued,  the  surgeon  will  frequently  have  the 
satisfaction  of  immediately  locating  the  cause  of  the  dis- 
turbance in  a  small  more  or  less  sensitive  tumor,  sometimes 
scarcely  larger  than  a  hazelnut,  situated  internal  to  the 
femoral  vessels.  The  rigid  walls  of  the  femoral  canal  (the 
pubic  bone  behind,  Poupart's  ligament  in  front,  Gimber- 
nat's  ligament  to  the  inner,  and  the  femoral  sheath  to  the 
outer  side),  together  with  its  narrowness,  contribute  greatly 
to  the  development  of  a  very  firm  strangulation,  which  is 
usually  of  the  elastic  variety.  The  same  factors  also  make 
taxis  much  more  difficult  in  the  great  majority  of  cases  than 
in  a  strangulated  inguinal  hernia,  for  example,  and  this 
procedure  must  consequently  be  employed  most  cautiously 


200  HERNIA. 

and  witliout  the  application  of  too  much  force.  As  a  fur- 
ther consequence  of  the  narrowness  of  the  femoral  canal 
hernias  of  the  intestinal  wall  are  observed  more  frequently 
here  than  elsewhere.  There  are  also  certain  points  which 
must  be  borne  in  mind  in  performing  lierniotomy.  The 
cutaneous  incision  is  made  in  a  longitudinal  direction,  and 
is  so  planned  that  its  center  corresponds  to  the  neck  of  the 
sac.  Great  caution  must  be  exercised  in  making  this  inci- 
sion,  since  we  have  seen  that  the  hernial  coverings  are  often 
very  thin,  and  sometimes  apparently  absent,  so  that  the 
operator  immediately  exposes  the  subperitoneal  areolar 
tissue  or  the  hernial  sac  itself.  The  subsequent  steps  of 
the  operation  are  easier  than  in  inguinal  hernia,  inasmuch 
as  the  hernial  sac  may  almost  always  be  readily  isolated 
from  the  surrounding  tissues  by  blunt  dissection.  After 
the  hernial  sac  has  been  opened  in  the  customary  manner 
and  its  contents  inspected,  the  operator  next  proceeds  to 
divide  the  constriction.  Since  profuse  and  even  fatal 
hemorrhages  were  formerly  greatly  feared  during  this  step 
of  the  operation,  brief  mention  should  be  made  of  some 
anomalies  of  the  origin  and  course  of  tlie  blood-vessels 
situated  in  this  region.  The  deep  epigastric  artery,  instead 
of  coming  from  the  external  iliac  just  behind  Poupart's 
ligament,  may  arise  higher  up  and  then  run  along  the  upper 
margin  of  the  neck  of  the  sac.  The  obturator  artery,  in- 
stead of  being  given  off  from  the  internal  ihac,  may  arise 
from  the  external  iliac  either  directly  or  indirectly  by  a 
trunk  common  to  itself  and  the  deep  epigastric  artery ;  in 
both  instances  the  anomalous  obturator  artery  lies  immedi- 
ately to  the  outer  side  of  the  neck  of  the  sac.  Tliis  common 
branch  of  origin  of  the  obturator  and  deep  epigastric  may 


FEMORAL  HERNIA.  201 

be  so  long  that  it  lies  just  above  the  sac,  while  the  obtu- 
rator artery  itself  lies  immediately  to  the  inner  side.  Since 
the  femoral  vein  lies  just  external  to  the  hernia,  the  neck 
of  the  sac  may  be  completely  surrounded  by  a  vascular 
wreath,  and  this  condition  Avas  formerly  so  feared  that  it 
received  the  name  of  corona  mortis.  It  consequently  fol- 
lows that  the  constriction  in  strangulated  femoral  hernia 
should  be  divided  only  from  without  inward,  so  that  any 
hemorrhage  may  be  immediately  recognized  and  controlled. 

THE  TREATMENT  OF  FEMORAL  fiERNIA. 

The  Treatment  by  Means  of  a  Truss. — The  state- 
ments made  in  reference  to  the  treatment  of  inguinal  her- 
nia by  a  truss  apply  to  a  great  extent  to  femoral  hernia, 
but  the  exact  application  of  the  truss  is  more  difficult, 
since  it  is  more  apt  to  be  displaced  by  the  movements  of 
the  hip-joint.  In  an  inguinal  hernia  the  truss  must  be  so 
applied  that  its  longest  diameter  corresponds  to  the  course 
of  Poupart's  ligament ;  in  the  femoral  variety  the  long  axis 
of  the  pad  must  be  more  vertical,  and  the  pad  itself  should 
be  smaller  and  narrower.  If  the  patient  allows  himself  to 
be  treated  exclusively  by  an  instrument-maker,  and  if  this 
individual,  as  not  infrequently  happens,  is  unable  to  decide 
as  to  Avhether  the  hernia  is  inguinal  or  femoral,  he  some- 
times tries  to  solve  the  difficulty  by  employing  a  large  pad 
which  almost  covers  both  hernial  orifices.  Berger  states 
that  the  French  instrument-makers  have  constructed  a 
special  truss  for  such  doubtful  cases  which  they  call  an 
inguino-femoral  truss,  and  which,  if  the  truth  Avere  told, 
is  not  suitable  for  either  an  inguinal  or  a  femoral  hernia. 

In  order  to  avoid  displacement  of  the  pad  every  femoral 


202 


HERNIA. 


truss  should  be  provided  with  a  perineal  strap,  which,  in 
contradistinction  to  that  of  the  inguinal  truss,  is  attached 
to  the  outer  edge  of  the  pad  and  is  carried  horizontally 
about  the  thigh  (Fig.  79). 

The  data  which  must  be  given  to  the  instrument-maker 
are  similar  to  those  necessary  in  the  inguinal  variety,  the 
pelvic  circumference  midway  between  the  anterior  superior 
spine  and  the  great  trochanter  being  particularly  required. 

The  Radical  Operation. — The  exposure  of  the  hernial 


Fig.  77. — Single  femoral  truss.  Fig.  78. — Double  femoral  truss. 


sac,  the  reduction  of  the  contents,  and  the  highest  possible 
ligation  and  extirpation  of  the  sac  are  carried  out  in  the 
radical  operation  of  femoral  hernia  as  has  previously  been 
described  in  the  section  upon  hernia  in  general,  and  in  that 
upon  inguinal  hernia,  by  a  longitudinal  incision  over  the 
hernial  tumor.  For  the  closure  of  the  hernial  orifice,  how- 
ever, special  methods  are  necessary  which  are  adapted  to 
the  special  anatomy  of  the  femoral  region.  If  the  hernial 
orifice  is  small,  it  may  usually  be  firmly  and  permanently 
closed  by  stitching  the  pectineal  fascia,  or,  still  better,  the 


FEMORAL  HERNIA.  203 

superficial  layers  of  the  pectineus  muscle  itself,  partly  to 
Poupart's  ligament  and  partly  to  the  falciform  process  of 
the  fascia  lata.     In  introducing  these  sutures  particular 


Fig.  79. — This  illustration  shows  the  method  of  application  of  a 
femoral  truss,  the  perineal  strap  passing  horizontally  about  the  thigh. 


care  must  be  taken  to  avoid  puncturing  the  immediately 
adjacent  femoral  vein. 

Bassini  performs  this  operation  by  making  an  incision 


204  HERNIA. 

immediately  below  and  parallel  to  Poupart's  ligament,  and 
passes  the  stitches  not  only  through  Poupart's  ligament 
and  the  pectineal  fascia,  but  also  through  the  periosteum 
of  the  horizontal  ramus  of  the  pubis. 

[I  believe  that  Bassini's  operation  for  femoral  hernia 
and  the  so-called  purse-string  method  meet  the  require- 
ments better  than  any  of  the  more  elaborate  methods  that 
have  been  brought  forward  from  time  to  time. 

I  have  personally  operated  upon  65  cases  of  femoral 
hernia,  in  16  of  which  Bassini's  method  Avas  used.  In  all 
the  others  I  employed  the  so-called  purse-string  method, 
originally  proposed,  I  believe,  by  Gushing,  of  Boston.  I 
consider  the  purse-string  method  superior  to  Bassini's  in 
most  cases,  except  possibly  those  with  a  very  large  opening. 
During  the  past  three  years  I  have  employed  this  method 
uniformly  in  all  cases,  without  selection,  and  in  49  cases 
in  which  I  have  used  it  during  the  past  eleven  years,  not 
a  single  relapse  has  been  observed. 

The  technique  in  brief  is  :  First,  to  thoroughly  free  the 
sac  well  beyond  the  neck ;  it  is  then  transfixed  and  tied 
off  so  high  up  that  when  it  retracts  there  is  no  longer  any 
funicular  process.  A  purse-string  suture  of  chromicized 
kangaroo-tendon  is  introduced  through  Poupart's  ligament 
or  the  inner  portion  of  the  roof  of  the  crural  canal,  from 
which  it  passes  downward  into  the  pectineal  fascia  and 
muscle,  forming  the  floor  of  the  canal,  then  outward,  pick- 
ing up  the  fascia  lata  overlying  the  femoral  vessels,  and 
finally  upward  through  Poupart's  ligament,  emerging  about 
J  inch  from  the  point  of  introduction.  On  tying  this 
suture  the  floor  of  the  canal  is  brought  into  perfect  apposi- 
tion with  the  roof  and  the  femoral  opening  is  obliterated. 


FEMORAL  HERNIA.  205 

This  method  is  much  simpler  than  Bassini's,  and  in  un- 
complicated cases  can  be  easily  performed  in  ten  to  fifteen 
minutes.  The  only  relapse  that  I  have  had  in  the  65  cases 
of  femoral  hernia  followed  an  operation  by  Bassini's  method 
in  a  woman  thirty-five  years  of  age.  This,  however,  was 
also  the  only  case  of  femoral  hernia  in  which  suppuration 
occurred,  and  this  fact,  doubtless,  was  responsible  for  the 
relapse.  At  present,  five  years  after  the  operation,  the 
patient  has  merely  an  exaggerated  impulse  and  has  never 
worn  a  truss. — Ed.] 

Kocher  employs  the  same  displacement  method  in  fem- 
oral hernia  that  he  has  described  for  the  inguinal  variety. 
An  incision  parallel  to  the  inner  third  of  Poupart's  liga- 
ment exposes  the  hernial  sac,  which  is  completely  isolated 
up  to  the  femoral  ring.  A  small  opening  is  now  made 
above  Poupart's  ligament  in  the  dense  tissue  of  the  outer 
pillar  of  the  external  abdominal  ring ;  a  dressing-forceps  is 
passed  through  this  opening,  behind  Poupart's  ligament, 
and  do\Mi  into  the  hernial  sac,  the  fundus  of  which  is 
seized,  pulled  out  through  the  opening,  and  sutured  as  in 
inguinal  hernia.  The  hernial  sac  is  fastened  in  the  fem- 
oral ring  by  passing  a  suture  through  Poupart's  ligament 
and  the  pectineal  fascia,  together  with  the  pubic  perios- 
teum, in  such  a  manner  that  it  includes  the  sac.  Poupart's 
ligament  is  then  stitched  firmly  to  the  pectineal  fascia  by 
two  or  three  sutures,  so  that  it  acts  as  a  support  and  exten- 
sion of  Gimbernat's  ligament ;  these  sutures  cannot  be  in- 
troduced immediately  alongside  of  the  femoral  vein,  since 
such  a  complete  closure  of  the  femoral  ring  might  result 
in  thrombosis.  The  superfluous  portion  of  the  hernial  sac 
is  extirpated. 


206  HERNIA. 

Fig.  80. — The  radical  operation  for  femoral  hernia.  The  stump  of 
the  hernial  sac  has  not  yet  slipped  back  into  the  abdomen  and  is  seen 
below  PoiTpart's  ligament  to  the  inner  side  of  the  femoral  vein.  The 
hernial  orifice  is  to  be  closed  by  four  sutures  which  pass  from  the 
pectineus  muscle  and  its  fascia  to  Poupart's  ligament  and  the  fascia 
lata. 


In  a  large  femoral  hernia  with  a  wide  hernial  orifice  the 
methods  jnst  described  will  not  be  sufficient,  and  the  fem- 
oral ring  must  be  closed  by  some  variety  of  plastic  opera- 
tion. 

Such  a  method  has  been  published  by  Salzer,  who,  after 
extirpating  the  sac  and  burying  the  stump  in  the  usual 
manner,  forms  a  short,  broad,  firm  flap  from  the  pectineal 
fascia,  the  pedicle  being  situated  above.  The  free  edge  of 
this  flap  is  stitched  to  the  middle  third  of  Poupart's  liga- 
ment, avoiding  all  tension,  and  thus  forms  a  new  firm 
fibrous  septum  crurale.  Since  the  pectineal  fascia  is  very 
frequently  an  extraordinarily  thin  connective-tissue  mem- 
brane, Schwartz's  modification  of  Salzer's  method  is  more 
appropriate,  and  consists  in  making  the  flap  from  the  entire 
thickness  of  the  pectineus  muscle  and  then  stitching  this 
flap  firmly  to  Poupart's  ligament  (Fig.  81). 

If  the  femoral  hernia  is  still  larger,  if  it  hangs  down 
upon  the  thigh,  and  if  several  fingers  can  be  comfortably 
introduced  into  the  hernial  orifice,  the  osteoplastic  opera- 
tion first  employed  by  Trendelenburg  and  Kraske  is  to  be 
recommended.  A  flap  consisting  of  periosteum,  cartilage, 
and  bone  is  chiseled  out  from  the  pubis,  extending  beyond 
the  symphysis  if  necessary.  This  flap  retains  its  connec- 
tion with  the  pelvis  by  the  periosteum  and  is  loosened 
sufficiently  to  allow  it  to  be  stitched  in  front  of  the  hernial 


Fig.  80. 


Ligam.  inguinale  (Poupartij. 

Sacciis  herniae  cruralis. 
^'ena  femoralis. 
M.  pectineus. 


FEMORAL  HERNIA.  207 

orifice  Avithout  tension.  Althouoh  suppnration  may  cause 
this  bone  flap  to  become  necrotic,  and  although  it  may  be 
absorbed  in  the  absence  of  suppuration  and  thus  make  the 
result  a  questionable  one,  the  employment  of  this  method 
would  seem  justifiable,  since  different  authors  have  operated 
upon  a  series  of  cases  and  attained  permanent  cures  where 
it  was  impossible  to  close  the  large  hernial  orifice  by  any 
other  procedure.  [We  are  strongly  of  the  opinion  that  a 
femoral  hernia  of  such  great  size  that  it  cannot  be  cured 
by  the  simpler  methods  described  had  better  not  be  oper- 
ated upon  than  be  treated  by  the  extensive  osteoplastic 
methods.  Though  an  occasional  cure  may  result,  the  fail- 
ure to  cure  leaves  the  patient  in  far  worse  condition  than 
prior  to  operation. — Ed.] 

Attempts  have  recently  been  made  by  AVitzel  to  obtain 
a  firm  closure  of  the  hernial  orifice  by  the  introduction  and 
inclosure  of  foreign  bodies — heteroplasty.  Witzel  formed 
a  close  network  of  silver  Avire  which  heals  in  the  wound  as 
a  firm  pad  and  forms  a  permanent  closure  of  the  hernial 
orifice.  A  sufficient  length  of  time  has  not  yet  elapsed  to 
allow  us  to  judge  of  the  permanency  of  the  results  obtained 
by  this  method.  [This  is  based  on  the  same  principle  as 
Phelps'  "wire  mattress"  method  in  inguinal  hernia. 
From  the  results  thus  far  observed,  as  well  as  from 
theoretic  considerations,  such  methods  are  of  doubtful 
value. — Ed.] 

All  operative  procedures  which  include  a  detachment 
of  Poupart's  ligament  should  be  condemned  on  account  of 
the  danger  of  the  secondary  development  of  an  inguinal 
hernia. 


208 


HERNIA. 


Fig.  81. — The  radical  operation  for  femoral  hernia  :  a,  Poupart's 
ligament  ;  b,  femoral  artery  ;  c,  the  stump  of  the  sac  which  has  not 
yet  been  buried  in  the  abdominal  cavity  ;  d,  femoral  vein  ;  e,  the  flap 
from  the  pectineus  muscle  ;  f,  sartorius  muscle  ;  g,  adductor  longus 
muscle.  The  two  sutures  which  have  been  passed  through  the  pec- 
tineus muscle  and  Poupart's  ligament  indicate  the  manner  in  which 
the  muscular  flap  is  secured  in  front  of  the  hernial  orifice. 


UMBILICAL  HERNIA* 

Umbilical  hernia  is  far  more  frequent  in  children  than 
in  adults,  and  occurs  particularly  in  girls.  In  order  to 
obtain  a  correct  idea  of  the  distribution  and  frequency  of 
these  cases  of  umbilical  hernia,  it  is  therefore  more  appro- 
priate to  consider  the  two  sexes  in  two  classes,  under  and 
over  fifteen  years  of  age.  The  following  figures,  from 
Berger's  statistics,  show  the  relative  percentages  of  umbil- 
ical hernias  : 


Over  15 
Ykars. 

Under  15 
Years. 

Total. 

Males 

2.15% 
22.16% 

22.42% 
65.24% 

5.46% 

Females 

27.34% 

Total 

7.45% 

31.02% 

11.02% 

The  forms  in  which  umbilical  hernia  may  appear  are  so 
distinct  that  they  must  be  sharply  differentiated,  and  are 
worthy  of  separate  consideration.  They  are  :  (I)  The  con- 
genital hernia  of  the  umbilical  cord  ;  (II)  the  umbilical 
hernia  of  children  ;  and  (III)  the  umbilical  hernia  of 
adults. 


Fig.  81. 


UMBILICAL  HERNIA.  209 

I.  THE  CONGENITAL  HERNIA  OF  THE  UMBILICAL 

CORD. 

Strictly  speaking,  the  hernia  of  the  uml)ilical  cord  (hamia 
funiculi  umbilicalw)  must  be  classified  with  the  malforma- 
tions, since  the  peritoneum  and  viscera  are  not  abnormally 
protruded,  but  they  remain  lying  in  front  of  the  anterior 
abdominal  wall,  as  is  the  case  in  an  early  stage  of  intra- 
uterine life,  and  the  normal  closure  does  not  take  place. 
The  formation  of  the  umbilical  cord  as  illustrated  in  the 
diagrammatic  drawings  in  figure  82,  taken  partly  from 
Gegenbauer,  will  be  of  value  in  obtaining  a  clear  under- 
standing of  this  process. 

It  will  be  seen  that  in  a  certain  stage  of  development 
the  anterior  abdominal  wall  is  open  in  the  region  of  the 
navel,  and  also  that  a  portion  of  the  intestine  may  develop 
outside  of  the  abdominal  cavity.  If  this  opening  in  the 
anterior  abdominal  wall  is  not  closed  at  birth,  a  condition 
exists  which,  strictly  speaking,  must  be  designated  as 
ectopia,  but  which  is  usually  called  a  hernia  of  the  umbili- 
cal cord.  As  a  further  indication  that  such  a  case  is  act- 
ually one  of  ectopia,  it  frequently  happens  that,  in  addition 
to  intestine,  the  liver,  or  even  the  liver  alone,  the  stomach, 
the  pancreas,  or  the  spleen  may  be  found  as  contents  of  the 
hernial  tumor.  The  coexistence  of  other  malformations, 
such  as  hare-lip  or  congenital  fissures  in  other  regions  of 
the  body,  is  by  no  means  unusual. 

The  outer  covering  of  the  hernia  of  the  umbilical  cord  is 
formed  by  the  distended  tissues  of  the  funiculus, — ?'.  e.,  by 
a  thin  layer  of  the  jelly  of  AVharton, — and  behind  this  is 
situated  the  hernial  sac,  wdiich,  according  to  French  authors 
(Berger),  is  a  thin  non- vascular  membrane  corresponding 
14 


210  HERNIA. 

In  figure  82,  I,  is  seen  the  longitudinal  section  of  an  embryo,  the 
ventral  surface  of  which  is  continuous  with  a  sac  (a),  lined  by  ento- 
derm and  invested  by  mesoderm,  which  is  called  the  yolk-sac.  At  the 
tail-end  of  the  embryo  is  seen  also  the  commencing  protrusion  of  the 
allantois,  while  over  the  back  of  the  embryo  the  ectoderm  is  raised  up 
in  folds  which  subsequently  unite  and  form  the  amniotic  cavity.  In 
figure  II  the  allantois  has  grown  larger  and  assumed  the  shape  of  a 
tube  (b)  communicating  with  the  hind-gut.  The  folds  of  ectoderm 
are  in  contact  over  the  dorsal  surface  of  the  embryo  ;  they  fuse  with 
each  other  in  this  situation  and  form  the  amniotic  cavity  (c).  In  the 
further  course  of  development  ( Fig.  Ill )  the  amniotic  cavity  enlarges 
from  the  formation  of  amniotic  fluid,  the  allantois  acquires  vessels, 
the  subsequent  umbilical  vessels,  and  further  changes  are  observed  in 
the  yolk-sac  and  in  the  allantois,  since  both  of  these  structures  be- 
come constricted  to  narrow  stalks  as  they  pass  into  the  abdominal 
cavity.  This  process  becomes  still  more  apparent  in  figure  IV.  The 
yolk-sac  (a)  has  become  much  smaller  and  is  connected  with  the 
abdominal  cavity,  strictly  speaking  with  the  hind-gut,  only  by  a 
narrow  canal,  the  omphalo-mesenteric  duct  ;  the  allantois,  which 
originally  received  the  secretions  of  the  Wolffian  bodies,  does  not 
entirely  lose  this  function,  since  a  portion  of  this  structure  remains 
permanently  as  the  urinary  bladder.  The  narrow  duct  connecting  the 
distal  portion  of  the  allantois  with  the  hind-gut  is  known  as  the 
urachus.  In  figure  V  the  formation  of  the  umbilical  cord  has  been 
completed.  The  amniotic  cavity  (c)  has  become  greatly  enlarged  and 
forms  a  sac,  filled  with  amniotic  fluid,  about  the  embrj^o  ;  the  blood- 
vessels of  the  allantois  have  combined  with  those  of  the  decidua  to 
form  the  chorion  and  subsequently  the  placenta.  The  abdominal 
cavity  has  become  closed  with  the  exception  of  the  point  of  entrance 
of  the  umbilical  cord,  which  is  composed  of  the  remains  of  the 
omphalo-mesenteric  duct,  of  the  urachus,  and  of  the  umbilical  vessels. 
After  the  chorion  has  formed  the  entodermic  portion  of  the  urachus 
(u)  remains  only  for  a  short  time,  while  its  outer  connective-tissue 
layer  becomes  transformed  into  the  jelly  of  A\liarton  which  surrounds 
the  umbilical  vessels.  The  remains  of  the  yolk-sac  (a)  are  known  as 
the  vitelline  vesicle,  while  the  omphalo-mesenteric  duct  becomes 
obliterated  toward  the  end  of  fetal  life  and  loses  its  connection  with 
the  intestine.  The  intestine  has  drawn  back  into  the  abdominal  cavity 
and,  if  the  development  is  normal,  there  is  no  longer  a  trace  of  the 
former  open  connection  between  it  and  the  yolk-sac  situated  outside 


Fig.  82. 


UMBILICAL  HERNIA.  211 

of  the  abdominal  caAity.  It  should  be  mentioned  that  in  pathologic 
cases  the  omphalo-mesenteric  duct  may  either  remain  as  an  umbilico- 
intestinal  fistula  or  it  may  become  obliterated,  with  the  exception  of 
its  intestinal  end,  which  is  then  designated  as  Meckel's  diverticulum 
(Fig.  13). 

in  its  position  to  the  peritoneum,  and  which,  like  a  true 
hernial  sac,  is  directly  continuous  with  the  parietal  perito- 
neum. The  entire  covering  is  as  thin  as  a  transparent 
veil,  so  that  the  underlying  structures  may  be  distinctly 
recognized.  The  coverings  of  the  umbilical  hernia  are 
sharply  defined  from  the  skin  of  the  abdomen,  which  is 
usually  continued  upon  the  umbilical  cord  for  a  short  dis- 
tance, rarely  more  than  one  centimeter. 

The  size  of  umbilical  hernias  is  subject  to  the  greatest 
variation.  If  only  the  convexity  of  an  intestinal  coil  pro- 
trudes, it  may  be  quite  difficult  to  decide  that  the  small 
swelling,  scarcely  as  large  as  a  hazelnut,  is  a  hernia  of  the 
umbilical  cord,  while  in  other  cases  there  is  an  eventration 
of  almost  all  of  the  abdominal  viscera,  and  between  these 
two  extremes  a  large  number  of  intermediate  degrees  will 
be  observed.  If  there  is  the  slightest  thickening  at  the 
commencement  of  the  umbilical  cord,  the  greatest  care 
must  be  exercised  in  its  ligation  to  avoid  including  the 
convexity  of  an  intestinal  coil. 

Immediately  after  birth  the  circulation  in  the  umbilical 
cord  ceases  from  the  sudden  fall  of  the  blood  pressure,  and 
the  stump  of  the  ligated  cord  becomes  necrotic,  shrivels  up, 
and  is  cast  off  after  several  days,  leaving  behind  a  small 
granulating  surface.  The  coverings  of  a  hernia  of  the 
umbilical  cord  naturally  undergo  the  same  fate  ;  they  dry 
up  and  are  cast  off,  sometimes  by  a  foul  suppurative  pro- 


212  HERNIA. 

PLATE  7. 

Hernia  of  the  Umbilical  Cord.— The  child  represented  in  the 
illustration  was  brought  to  the  surgical  clinic  at  Gottingen  on  March 
27,  1900,  five  hours  after  its  delivery.  In  the  umbilical  region  there 
was  a  round  tumor  the  size  of  an  apple  which  was  connected  with  the 
abdomen  by  a  pedicle  eight  centimeters  in  circumference.  The  skin 
of  the  abdomen  was  continued  upon  this  pedicle  for  a  distance  of 
almost  three  centimeters,  where  it  ended  as  a  sharp  border,  beyond 
which  a  transparent  membrane,  as  thin  as  paper,  covered  the  remain- 
ing portion  of  the  tumor  as  far  as  its  distal  extremity,  where  the  cov- 
erings were  drawn  out  like  a  funnel  and  became  continuous  with  the 
ligated  umbilical  cord.  The  umbilical  vessels  could  be  felt  as  a  cord 
on  the  lower  surface  of  the  tumor.  A  convolution  of  intestinal  coils, 
distinctly  recognized  through  the  hernial  coverings,  could  be  reduced 
into  the  abdominal  cavity,  a  gurgling  murmur  being  heard  at  the  time 
of  reduction. 

The  child  was  immediately  anesthetized,  the  cutaneous  ring  about 
the  base  of  the  pedicle  was  circumscribed  by  an  incision,  and  the  en- 
tire hernial  sac  and  its  coverings  were  extirpated.  The  abdominal 
cavity  was  then  immediately  closed  by  four  sutures  passing  through 
the  entire  thickness  of  the  abdominal  wall  and  the  small  wound  was 
covered  with  an  airol-adhesive  plaster  dressing.  After  an  uneventful 
recovery  the  child  was  discharged  April  11,  1900. 

cess,  so  that  the  abdominal  viscera  are  exposed.  In  these 
cases  the  consequent  suppurative  peritonitis  usually  brings 
about  a  rapid  and  fatal  termination.  It  is  only  when  the 
hernia  of  the  cord  is  very  small,  and  when  the  sloughing  of 
the  coverings  is  slow  enough  to  allow  the  formation  of  firm 
adhesions  between  the  protruding  viscera  and  the  par'etal 
peritoneum,  that  a  spontaneous  cure  is  possible. 

From  an  etiologic  standpoint  it  is  scarcely  possible  to 
separate  the  fissure-like  formations  of  the  anterior  abdom- 
inal wall  from  the  typical  hernia  of  the  umbilical  cord 
which  has  just  been  described.  Tliey  are  situated  just 
above  the  navel,  however,  and  consequently  cannot  be  des- 


Tab.  ?. 


.  Anst.  F.  BjRLcMwld,  Miiiwhen 


UMBILICAL  HERNIA.  213 

ignated  as  hernias  of  the  cord.  The  viscera  do  not  pro- 
trude into  the  base  of  the  umbilical  cord,  but  displace  tliis 
structure  downward  as  a  whole,  as  is  shown  in  Plate  8. 

The  Treatment  of  Congenital  Hernia  of  the  Umbil- 
ical Cord. — In  very  small  hernias  of  the  cord  recovery 
may  be  ol:)tained  without  operation  by  aiding  the  process 
which  has  previously  been  designated  as  the  spontaneous 
cure.  This  is  done  by  carefully  disinfecting  the  umbilical 
region,  reducing  the  hernia,  covering  tlie  hernial  orifice 
with  a  sterile  piece  of  gauze,  and  supporting  the  abdominal 
wall  by  strips  of  adhesive  plaster,  as  shown  in  figures  87 
and  88. 

If  the  hernia  of  the  umbilical  cord  is  larger,  however,  a 
cure  will  scarcely  ever  be  obtained  without  an  operation 
performed  at  the  earliest  possible  moment. 

The  radical  operation  for  hernia  of  the  umbilical  cord 
introduced  by  Lindfors  in  1881  had  few  adherents  in  the 
beginning,  but  now  has  a  large  series  of  cures  to  its  credit, 
and  these  are  particularly  worthy  of  note  in  view  of  the 
great  dangers  incurred.  In  1900,  Hansson  published  a 
collection  of  73  cases  treated  in  the  antiseptic  period  in 
which  there  were  : 

6  deaths  in   11  cases  treated  by  conservative  methods ; 

0  "         "2      "  "         "    simple  ligation ; 

1  death      ''      5      "  "         "    percutaneous  ligation ; 

0  deaths    ' '      5      "  "         "    extraperitoneal  operations ; 

17       "         "    50      "  "         "    radical  operation. 

Total,  73  hernias  of  the  cord  with  24  deaths,  a  mortality  of  32.8% . 

.  This  table  also  show^s  the  diiferent  measures  wdiich  have 
been  adopted  in  the  operative  treatment  of  this  affection. 
The  simple  ligation  of  the  pedicle  of  the  hernial  tumor  be- 


214  HERNIA. 

PLATE  8. 
A  Sagittal  Section  of  a  Newborn  Child  with  Ectopia  of  the 

Liver. — The  liver,  together  with  the  gall-bladder,  protrudes  through 
a  fissure  extending  from  the  navel  to  the  xiphoid  cartilage  in  the 
median  line  of  the  anterior  abdominal  wall  and  causes  a  spherical 
swelling  as  large  as  the  fist  the  outer  covering  of  which  is  formed  by  a 
bilaminar,  thin  transparent  membrane.  The  inner  lamella  of  this 
membrane  is  continuous  with  the  parietal  peritoneum.  The  umbilical 
cord  is  unchanged  throughout  and  displaced  downward. 


yond  the  cutaneous  margin  and  the  percutaneous  ligation 
of  Breus  are  worthy  of  little  recommendation,  since  the 
parts  ligated  cannot  be  seen  and  there  is  consequently  dan- 
ger of  including  portions  of  viscera  within  the  ligature.  A 
second  objection  is  that  these  methodsj  even  though  suc- 
cessful, do  not  close  the  abdominal  opening.  A  better 
operation  is  the  extraperitoneal  method  employed  by 
Olshausen,  who  cuts  through  the  skin  only  at  a  small  dis- 
tance from  the  cutaneous  margin  and  draws  back  tlie 
amnion  and  the  jelly  of  Wharton  from  the  hernial  sac. 
After  the  replacement  of  the  sac,  which  is  stitched  into 
several  folds,  the  wound  is  closed  by  a  number  of  deep 
and  superficial  sutures.  Even  in  this  method  the  opera- 
tion is  partly  done  in  the  dark  and  the  hernial  contents 
cannot  be  inspected.  For  this  reason  the  majority  of  sur- 
geons perform  the  radical  operation  of  Lindfors,  whicli 
consists  of  the  following  steps  :  The  opening  of  the  hernial 
sac,  the  reduction  of  the  contents,  the  circumcision  of  the 
umbilical  ring  close  to  the  cutaneous  margin,  the  extirpa- 
tion of  the  superfluous  portion  of  the  hernial  sac  together 
witli  its  coverings,  and  the  closure  of  the  abdominal  wound, 
either  layer  by  layer  (peritoneum,  muscle  and  fascia,  skin) 


Tab.  8. 


Liih.  Anst  F.  ReichkoLd,  Miincfien. 


UMBILICAL  HERNIA.  215 

or  by  sutures  passed  through  the  eutire  thickness  of  the 
abdominal  wall. 

If  the  hernia  of  the  umbilical  cord  is  very  large,  so 
many  viscera  protruding  that  the  abdominal  cavity  is  too 
small  to  allow  of  their  reduction,  the  outlook  is  naturally 
very  bad.  Even  in  such  cases  attempts  have  been  made 
to  effect  a  cure  by  a  partial  resection  of  the  protruding 
liver  (Arndt-Runge). 

IL  THE  UMBILICAL  HERNIA  OF  CHILDREN. 
If  the  development  of  the  umbilical  cord  is  normal,  the 
umbilical  ring  in  the  newborn  is  so  small  that  it  only 
allows  space  for  the  passage  of  the  umbilical  vessels. 
The  umbilical  cord  slouo^hs  off  a  few  davs  after  birth,  leav- 
ing  behind  a  small  granulating  surface  which  rapidly 
cicatrizes  and  becomes  covered  with  epithelium  from  the 
cutaneous  margin.  The  circular  umbilical  ring  can  still 
be  easily  felt,  the  upper  margin  more  distinctly  because 
the  umbilical  vein  is  more  loosely  attached  in  this  situation 
than  are  the  arteries  which  are  firmly  adherent  to  the 
lower  margin.  Since  the  umbilical  scar  is  composed  only 
of  the  skin,  the  transversalis  fascia,  together  with  some 
reinforcing  fibers  designated  as  the  umbilical  fascia,  and 
the  peritoneum,  and  only  becomes  smaller  and  more  firmly 
closed  as  the  child  grows,  it  is  readily  understood  that  this 
thin  scar  may  yield  when  the  child  cries  and  lead  to  the 
development  of  a  hernia.  To  clearly  understand  the  origin 
of  this  variety  it  is  important  to  remember  that  the  umbil- 
ical hernia  of  children  does  not  develop  until  the  navel 
has  cicatrized.  On  account  of  the  loose  attachment  of  the 
umbilical  vein  at  the  upper  margin  of  the  umbilical  ring. 


216 


HERNIA. 


Fig.  83. — An  umbilical  hernia  in  a  child  three  years  and  six  months 
of  age  :  The  hernia  is  almost  as  large  as  a  walnut  and  conical  in  shape. 
The  skin  of  "the  umbilicus  is  greatly  distended  and  a  small  scar  is  still 
visible  upon  the  extreme  convexity  of  the  hernia. 


UMBILICAL  HERNIA.  217 

the  hernia  usually  protrudes  between  this  margin  and  the 
vein. 

The  umbilical  hernia  of  children  usually  remains  quite 
small,  and  is  often  so  diminutive  that  it  is  entirely  over- 
looked. In  these  mildest  cases  the  hernia  protrudes  as  a 
swelling,  varying  in  size  from  that  of  a  pea  to  that  of  a 
bean,  only  during  crying  or  sneezing,  and  goes  back  spon- 
taneously as  soon  as  the  augmentation  of  the  intra-abdom- 
inal pressure  ceases.  The  umbilical  hernias  as  large  as  a 
cherry  or  walnut  (Fig.  83)  also  do  not  usually  appear  until 
the  patient  strains.  It  is  only  in  very  rare  cases  that  the 
umbilical  hernia  of  children  assumes  still  larger  dimen- 
sions. 

When  the  hernias  are  small,  they  are  usually  spherical 
in  shape ;  if  they  become  larger,  they  ordinarily  assume  a 
conical  form.  In  the  beginning  the  skin  of  the  umbilicus 
is  unchanged  in  form  and  appearance,  but  as  the  hernia 
increases  in  size  it  gradually  becomes  flatter,  distended, 
and  only  recognizable  as  a  small  flat  scar  upon  the  extreme 
convexity  or  upon  the  under  surface  of  the  hernia.  The 
umbilical  ring,  seen  from  within  (Figs.  84  and  85),  is  al- 
most always  circular  and  possessed  of  a  sharp  margin.  In 
this  form  of  hernia  strangulation  is  extremely  rare. 

The  small  umbilical  hernias  frequently  undergo  sponta- 
neous cure  by  the  subsequent  contraction  and  complete 
closure  of  the  umbilical  ring  during  the  course  of  the  first 
and  second  years. 

The  Treatment  of  Umbilical  Hernia  in  Children. — 
On  account  of  the  small  size  of  these  hernias,  and  of  their 
tendency  to  spontaneous  cure,  operations  are  but  rarely 
necessary.     The  treatment  must  be  commenced  as  early  as 


218 


HERNIA. 


possible,   however,   in   order  to   keep  the  hernial   orifice 
closed  by  an  appropriate  support,  and  in  this  manner  aid 


Fig.  84  represents  a  view  from 
within  of  a  section  of  the  an- 
terior abdominal  wall  of  a  child, 
less  than  one  year  old,  affected 
with  an  umbilical  hernia.  The 
situation  of  the  navel  is  recog- 
nized by  the  three  folds  of  peri- 
toneum which  converge  toward  it 
from  the  bladder  ;  and  as  the  her- 
nial contents  have  been  removed, 
the  interior  of  the  sac  is  exposed. 
The  umbilical  ring  is  markedly 
dilated  ;  its  margin  is  sharp  and 
almost  circular. 


Fig.  85  shows  the  same  speci- 
men with  an  intestinal  coil  as  the 
contents  of  the  hernia. 


the  natural  tendency  to  recovery.  These  hernias  are  found 
chiefly  in  children  under  one  year  of  age,  and  as  all  vari- 
eties of  trusses  are  more  or  less  impracticable  at  this  time, 


UMBILICAL  HERNIA.  219 

since  too  much  pressure  is  necessary  to  keep  them  from 
changing  their  position,  other  methods  of  retention  must 
be  employed.  The  most  appropriate  one  is  the  adhesive 
plaster  dressing,  which  meets  every  requirement  and  has 
the  additional  merit  of  simplicity.  As  in  the  application 
of  any  other  retentive  apparatus,  the  hernia  must  first  be 
reduced  and  the  adhesive  plaster  may  then  be  employed  in 
one  of  two  ways.  The  first  method  is  to  make  a  pad  of 
ten  or  twelve  folds  of  adhesive  plaster  so  that  a  small  disc 
about  three  millimeters  (J  of  an  inch)  thick  is  obtained. 
This  disc  is  then  cut  out  so  that  its  diameter  is  at  least  one 
centimeter  greater  than  that  of  the  hernial  orifice.  A  pad 
as  large  as  a  quarter  will  usually  be  sufficient.  The  pad 
is  fastened  over  the  umbilical  ring  by  means  of  two  or 
three  strips  of  rubber  adhesive  plaster  eight  to  ten  inches 
in  length.  A  better  method  is  that  shown  in  figures  86 
and  87.  After  the  hernia  has  been  reduced,  the  navel  is 
invaginated  and  the  neighboring  skin  raised  up  in  two 
folds,  which  are  fixed  in  this  position  by  means  of  three 
strips  of  adhesive  plaster  eight  to  ten  inches  in  length. 
None  of  the  strips  should  pass  entirely  around  the  abdo- 
men. [At  the  Hospital  for  Ruptured  and  Crippled  we  have 
for  many  years  employed  a  strip  of  plaster  two  inches 
wide  entirely  encircling  the  abdomen.  A  pad  consisting 
of  a  wooden  button,  \\  inches  in  diameter  and  covered 
with  plaster,  is  applied  over  the  hernia.  This  method  has 
given  very  satisfactory  results. — Ed.]  If  the  rubber 
adhesive  is  of  good  quality,  such  a  dressing  may  remain 
unchanged  for  two  or  three  weeks  without  irritating  the 
skin,  and  the  children  may  be  bathed  without  loosening 
the  strips.     Before  the  application  of  a  fresh  dressing,  all 


Fig.  86. — The  application  of  an  adhesive  plaster  dressing  for  um- 
bilical hernia  :  The  right  hand  has  invaginated  the  navel  and  drawn 
the  adjacent  skin  into  two  folds  ;  a  strip  of  adhesive  plaster  is  applied 
to  the  left  side,  stretched  tightly  across  these  folds  to  retain  them  in 
position,  and  secured  upon  the  right  side. 


^ 


Fig.  87.— The  first  strip 
has  been  applied  and  two 
overlapping  strips,  one  above 
and  one  below,  have  been 
partly  adjusted.  They  are 
to  be  drawn  over  and  se- 
cured upon  the  left  side,  as 
was  the  first  strip. 


220 


UMBILICAL  HERNIA. 


221 


particles  of  adhesive  must  be  carefully  removed  with  ether, 
and  it  is  also  well  to  postpone  the  general  bath  until  this 

time. 

If  the  children  are  somewhat  older,  some  of  the  rubber 
trusses  (Fig.  88)  found  in  the  shops  may  be  employed. 
These  trusses  are  made  of  soft  rubber  throughout,  the 
hernial  orifice  being  covered  by  a  flat  rubber  pad  which 
has  an  elevated  central  portion.  This  elevation  must,  of 
course,  be  larger  than  the  diameter  of  the  hernial  orifice, 
so  that  it  does  not  project  into  the  hernial  ring  like  a  cone, 


Fig.  88. 


in  which  case  it  would  only  dilate  the  mouth  of  the  hernia. 
The  truss  is  provided  with  eyelets  so  that  it  may  be  laced 

at  the  back. 

The  treatment  just  mentioned  must  sometimes  be  con- 
tinued for  a  long  period  of  time,  since  a  complete  cure  may 
be  expected  even  after  several  years. 

The  radical  operation  is  indicated  if  the  hernia  shows 
no  tendency  to  recovery  in  spite  of  several  years  of  treat- 
ment with  retentive  dressings,  and  particularly  if  it  com- 
mences to  enlarge.  The  operation  is  best  performed  by 
first  cutting  around  and  completely  removing  the  navel 


222  HERNIA. 

{omphalectomy) ;  the  hernial  sac  is  then  extirpated  and  the 
wound  closed  like  any  laparotomy  wound  in  the  linea  alba. 
The  borders  of  the  recti  muscles  should  be  freely  exposed, 
and  it  is  best  to  pass  the  sutures  through  all  the  layers  of 
the  abdominal  wall.  The  sutures  should  be  introduced 
from  Avithin  outward  through  the  peritoneum,  the  recti 
muscles  and  their  aponeuroses,  and  the  skin ;  none  of  the 
sutures  should  be  tied  until  all  of  them  have  been  intro- 
duced. [We  believe  that  better  results  Avill  be  obtained 
by  suturing  the  wound  in  layers.  It  is  seldom  necessary 
to  operate  under  the  age  of  fourteen  years. — Ed.] 

m.  UMBILICAL  HERNIA  IN  ADULTS* 
The  causes  of  the  development  of  this  form  of  umbilical 
hernia  differ  essentially  in  their  nature  from  those  of  the 
other  two  varieties.  The  umbilical  region  has  attained  a 
normal  degree  of  firmness,  but  has  secondarily  become 
relaxed  and  yielding.  One  of  the  chief  causes  of  develop- 
ment is  the  distention  and  relaxation  of  the  abdominal 
wall  that  occurs  after  repeated  pregnancies,  and  the  great 
majority  of  cases  of  this  variety  are  consequently  observed 
in  women.  Other  causes,  however,  may  produce  the  same 
eifect.  Increasing  obesity,  for  example,  may  cause  the 
umbilicus  to  project  more  and  more  until  it  becomes  so 
distended  that  a  hernial  protrusion  results.  This  is  par- 
ticularly liable  to  occur  when  an  obese  individual  rapidly 
emaciates,  since  the  distended  abdominal  Avail  becomes 
completely  relaxed  by  the  emaciation.  Occasionally  an 
antecedent  suppuration  may  diminish  the  resistance  of  the 
umbilical  scar  and  lead  to  the  development  of  a  hernia 
(Fig.  89).      While  these  hernias  are  small  it  may  some- 


UMBILICAL  HERNIA.  223 

times  be  detormined  that  they  do  not  protrude  through  the 
navel  itself,  but  to  one  side,  and  this  variety  has  conse- 
quently been  called  a  parumbilical  hernia.  This  differ- 
ence completely  disappears,  however,  with  the  increasing 
size  of  the  protrusion.  These  hernias  frequently  grow  to 
a  considerable  size,  not  infrequently  reaching  that  of  a 
man's  fist,  of  a  child's  head,  or  attaining  still  larger  dimen- 
sions. They  ordinarily  have  a  broad  base  in  the  umbili- 
cal region  and  a  spherical  form  which  sometimes  becomes 
somewhat  conical  at  the  distal  extremity  of  the  protrusion. 

The  longer  the  large  umbilical  hernia  of  the  adult  exists, 
the  more  exposed  it  is  to  injurious  influences,  since  the 
coverings  consist  only  of  peritoneum,  transversalis  fascia, 
and  distended  skin,  and  the  exposed  position  of  the  hernia 
favors  all  sorts  of  mechanical  irritation  such  as  that  pro- 
duced by  the  rubbing  of  the  clothes.  The  herniated  vis- 
cera are  frequently  adherent  to  each  other  and  to  the  wall 
of  the  sac  ;  the  hernia  becomes  irreducible,  and  if  the 
inflammatory  phenomena  continue  diverticula  are  not  in- 
frequently formed  by  the  adhesion  of  folds  of  the  hernial 
sac.  In  addition  to  all  this,  septa  may  be  formed  dividing 
the  hernial  sac  into  a  number  of  loculi  Avhich  may  be  filled 
with  fluid  and  walled  ofl*  by  adherent  omentum  (Konig). 
It  is  therefore  easily  understood  that  considerable  difficulty 
may  be  encountered  in  operating  upon  one  of  these  large 
umbilical  hernias. 

Strangulation  is  not  uncommon  in  the  umbilical  hernias 
of  adults,  and,  from  the  reasons  previously  stated,  has  a 
graver  prognosis  than  strangulation  occurring  either  in 
inguinal  or  In  femoral  hernia.  Isolated  cases  may  be  par- 
ticularly complicated  by  the  strangulation  of  an  intestinal 


224 


HERNIA. 


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Fig.  90. — A  semi-diagrammatic  section  through  a  strangulated  um- 
bilical hernia  in  an  obese  woman,  who  had  suffered  from  the  umbilical 
hernia  for  the  previous  fifteen  years.  The  symptoms  of  strangulation 
had  existed  for  nine  daj^s.  When  the  herniotomy  was  performed, 
unchanged  intestine  and  omentum  were  found  in  the  hernial  sac, 
which  possessed  a  number  of  diverticula,  and  it  was  not  until  an 
attempt  was  made  to  draw  the  intestine  forward  that  an  intestinal 
coil  was  found  which  had  passed  into  one  of  these  diverticula  and  be- 
come strangulated  in  this  situation.  The  illustration  shows  a  number 
of  septa,  and  in  one  of  the  diverticula  formed  by  these  septa  is  seen 
the  strangulated  intestinal  coil.  Two  of  the  other  diverticula  con- 
tained omentum,  w^hile  the  remaining  portion  of  the  sac  contained  the 
distended  afferent  and  the  collapsed  efferent  intestine.  A  similar  case 
has  been  described  by  Eiedel. 

15  225 


226 


HERNIA. 


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UMBILICAL  HERNIA.  227 

coil  within  a  diverticulum  of  the  hernial  sac  (Fig.  90),  the 
remainder  of  the  hernial  contents  being  found  in  the  sac  in 
a  non-strangulated  condition.  [The  mortality  of  opera- 
tions for  strangulated  umbilical  hernia  is  fully  50^. — 
Ed.] 

In  the  differential  diagnosis  many  affections  must  be 
considered.  Solid  tumors  in  the  umbilical  region,  appear- 
ing either  primarily  or  as  metastatic  deposits  from  a 
primary  focus  which  is  usually  situated  in  the  gastro-intes- 
tinal  tract,  Avill  rarely  cause  confusion  if  they  are  carefully 
examined.  It  is  much  more  likely  that  a  subperitoneal 
lipoma  in  the  umbilical  region  (Fig.  91)  will  be  mistaken 
for  an  umbilical  hernia.  It  is  true  that  the  umbilicus 
itself  is  a  scar,  and  as  such  contains  no  subperitoneal 
areolar  tissue,  but  the  immediately  adjacent  subperitoneal 
areolar  tissue  not  infrequently  grows  and  forms  a  lipoma 
which  enlarges  toward  the  navel  and  finally  assumes  its 
position.  If  the  differential  points  given  on  page  62 
are  borne  in  mind,  however,  it  will  almost  always  be  pos- 
sible to  form  a  correct  diagnosis. 

The  Treatment  of  the  Umbilical  Hernias  of  Adults. 
— As  long  as  the  hernias  are  reducible,  abdominal  ban- 
dages or  trusses  may  be  employed,  not  with  the  idea  of 
curing  the  hernia,  but  for  the  purpose  of  alleviating  the 
symptoms  and  preventing  the  enlargement  of  the  hernia. 
For  this  purpose  a  pad  adapted  to  the  curve  of  the  abdo- 
men is  employed  which  should  have  a  flat  elevation  upon 
its  inner  surface  in  order  to  exert  a  firmer  pressure  upon 
the  hernial  orifice.  It  must  again  be  emphasized  that  this 
elevation  must  be  larger  than  the  hernial  ring  (Fig.  92), 
so  that  it  cannot  form  a  conical  projection  into  the  mouth 


228 


HERNIA. 


of  the  hernia.  Straps  are  fastened  to  a  number  of  but- 
tons upon  the  outer  surface  of  the  pad,  Avith  which  it  is 
buckled  firmly  about  the  abdomen.  In  order  to  hold  the 
pad  in  position,  perineal  straps  must  frequently  be  em- 
ployed, which  are  usually  very  irksome  to  the  patient.  If 
the  hernia  is  irreducible,  and  if  any  contraindication  to  an 
operation  exists,  the  patient  must  wear  an  abdominal  sus- 
pensory such  as  that  emj^loyed  for  the  so-called  pendulous 
abdomen.     An  abdominal  bandage  has  been  described  by 


Fiff.  92. 


Hoffa,  which  prevents  any  displacement  and  at  the  same 
time  furnishes  a  good  support  for  the  hernia  (see  also  page 
262).  The  fixation  of  this  dressing  is  furnished  by  two 
metallic  supports,  similar  to  those  employed  in  a  scoliosis- 
corset,  which  are  molded  to  fix  the  crests  to  the  ilia,  and 
to  these  supports  is  fastened  the  abdominal  bandage,  which 
accurately  corresponds  to  the  form  of  the  individual. 

The  radical  operation  is   indicated   in  all  those   forms 
in  which  the  hernia  is  increasing  in  size,  and  if  possible  it 


UMBILICAL  HERNIA.  229 

should  be  performed  at  a  time  when  the  previously  de- 
scribed inflammatory  changes  have  not  yet  taken  place. 
The  prospects  for  recovery,  in  reference  to  the  operation 
in  general,  to  the  healing  of  the  Avound,  and  also  to  the 
deveh)pment  of  recurrences,  are  much  more  favorable  if 
the  hernia  is  still  small,  if  it  is  reducible,  and  if  no  inflam- 
matory changes  are  present.  A  marked  advance  in  the 
technic  of  the  radical  operation  was  made  by  Gersuny, 
who  suggested  opening  the  sheaths  of  the  recti  and  uniting 
the  internal  borders  of  these  muscles  in  addition  to  the 
customary  sutures  of  the  hernial  orifice.  Since  the  fibrous 
tissue  of  the  dilated  umbilical  ring  remains,  and  may  easily 
give  rise  to  a  recurrence,  it  is,  however,  more  appropriate 
to  perform  omphalectomy  as  perfected  by  Condamin  and 
Avarmly  recommended  by  v.  Bruns.  [The  more  recent 
method,  described  by  Piccoli  and  by  Blake  of  Xew  York, 
of  overlapping  the  recti  muscles,  seems  to  offer  advantages 
over  other  methods. — Ed.] 

In  spite  of  every  precaution  recurrences  are  observed 
more  frequently  than  in  other  hernial  regions,  since  the 
causes  of  the  development  of  the  hernia,  such  as  obesity 
and  relaxation  of  the  abdominal  wall  from  pregnancy, 
continue  to  exert  their  influence  after  the  operation.  If  the 
hernia  is  irreducible  or  annoying  on  account  of  its  size,  the 
operation  has  at  least  the  advantage  that  an  appropriate 
abdominal  bandage,  always  applied  after  operations  upon 
such  cases,  prevents  the  reappearance  of  the  troublesome 
symptoms. 

In  comparison  to  the  previously  described  varieties  of 
hernia  there  are  others  of  rarer  occurrence,  an  exact  knowl- 
edge of  which  is  of  no  less  importance,  particularly  in  ref- 


230  HERNIA. 

erence   to   the  early  recognition  of  strangulation  in  these 
situations. 

OBTURATOR  HERNIA. 

An  obturator  hernia  is  one  which  passes  through  the 
obturator  canal  and  appears  upon  the  anterior  surface  of 
the  thigh.  Since  the  discovery  and  first  description  of 
this  form  of  hernia  by  Arnaud  de  Ronsil  (1720),  a  rather 
large  number  of  cases  have  been  recorded,  but  the  total 
number  is  comparatively  so  small  that  the  description  of 
individual  cases  is  still  considered  worthy  of  being  pub- 
lished. AVith  the  exception  of  numerous  cases  in  which 
the  affection  was  first  recognized  at  operation  or  upon  the 
postmortem  table,  the  diagnosis  has  hardly  ever  been  made 
unless  strangulation  was  present,  and  this  explains  the 
fact  that  Berger  could  discover  only  one  obturator  hernia 
among  10,000  hernia  patients  who  were  ordered  trusses  at 
the  Central  Bureau  of  Paris. 

ANATOMY. 

The  obturator  foramen  is  almost  completely  closed  by  a 
striated  membrane, — the  obturator  membrane  (Fig.  93), 
— which  is  only  patulous  in  its  upper  and  outer  portion 
where  the  obturator  canal  gives  passage  to  the  obturator 
vessels  and  nerve.  The  upper  boundary  of  this  canal  is 
formed  by  the  obturator  sulcus  upon  the  inferior  surface 
of  the  horizontal  ramus  of  the  pubis. 

The  pelvic  surface  of  the  obturator  membrane  is  covered 
by  the  obturator  internus  muscle,  in  which  there  is  a 
fissure,  corresponding  to  the  obturator  canal,  for  the  pas- 
sage of  the  vessels  and  nerve.     The  hernia,  after  passing 


OBTURATOR  HERNIA. 


231 


through  the  obturator  canal  alongside  of  the  vessels,  comes 
in  contact  with  two  rigid  muscles,  the  obturator  externus 
and  the  pectineus,  and  this  accounts  for  the  fact  that  a  pro- 
trusion is  not  visible  externally  until  the  hernia  has 
attained   a    relatively    late    stage   of  development.      The 


Fig.  93. — A  bony  pelvis  in  which  the  obturator  membrane  (b)  has 
been  left  in  the  right  obturator  foramen.  The  membrane  entirely 
fills  the  foramen,  with  the  exception  of  an  opening  (a)  which  is  desig- 
nated as  the  obturator  canal.  It  is  through  this  opening  that  the 
obturator  hernia  escapes,  the  obturator  vessels  and  nerve  being  pushed 
to  one  side. 


obturator  externus  muscle  arises  from  the  inner  and  lower 
margin  of  the  obturator  foramen ;  its  fibers  are  in  imme- 
diate contact  with  the  obturator  membrane  and  pass 
directly  outward  to  the  trochanteric  fossa.  In  front  of 
the  obturator  externus  is  the  pectineus  muscle,  which  arises 
from  the  horizontal  ramus  of  the  pubis   and   passes  from 


232  HERNIA. 

Fig.  04. — Anterior  view  of  an  obtnrator  hernia:  A  part  of  the  pec- 
tineus  and  the  entire  obturator  externus  muscle  have  been  removed, 
exposing  the  bony  pelvis  and  a  portion  of  the  obturator  membrane. 
The  iliopsoas  and  pectineus  muscles  have  been  drawn  apart,  and 
between  them  lie  the  stumps  of  the  femoral  vessels.  The  sac  of 
the  obturator  hernia  has  been  opened  and  an  intestinal  coil  is 
seen  within,  a,  Poupart's  ligament;  b,  iliopsoas  muscle;  c,  femoral 
artery;  d,  femoral  vein;  e,  spermatic  cord;  f,  upper  stump  of  the  pec- 
tineus muscle;  g,  sartorius  muscle;  h,  obturator  hernia;  i,  obturator 
membrane;  k,  adductor  longus;  1,  lower  stump  of  the  pectineus  muscle. 

above  downward  and  from  within  ontward  to  be  inserted 
into  the  femnr  below  the  lesser  trochanter.  The  hernia 
itself  and  its  relations  to  the  neighboring  muscles  and  ves- 
sels are  shown  in  figure  94. 

The  size  of  the  hernia  is  usually  inconsiderable  on 
account  of  the  narrowness  of  the  obturator  canal,  and,  for 
the  same  reason,  hernia  of  the  intestinal  wall  may  easily 
develop  in  this  situation.  Owing  to  tlie  position  of  the 
hernia  behind  the  muscles,  the  visible  external  swelling  is 
flat  and  obscurely  defined.  It  is  only  Avhen  the  hernia 
attains  a  considerable  size  that  it  thins  and  distends  tlie 
overlying  muscles  or  pushes  between  their  individual 
fibers  ;  in  such  cases  a  large  protrusion  may  develop  wln'ch 
extends  upward  and  is  usually  regarded  as  a  femoral 
hernia. 

Subperitoneal  lipomas  are  not  rare  in  this  situation. 

THE   DIAGNOSIS    OF    OBTURATOR   HERNIA. 

From  wliat  has  been  said  of  the  anatomy  of  the  part, 
the  depth  of  the  hernia  protected  by  overlying  muscles 
and  the  consequent  difficulty  of  diagnosis  have  been  suffici- 
ently emphasized.     There  are,  nevertheless,  characteristic 


Fig.  94. 


OBTURATOR  HERNIA.  233 

cases  in  which  an  exact  diagnosis  may  be  made,  altliough 
they  are  usually  those  in  which  strangulation  is  present. 
The  most  important  indication  of  the  presence  of  an  obtu- 
rator hernia  is  the  Howship-Romberg  symptom,  which  is 
produced  by  the  pressure  of  the  hernial  protrusion  upon 
the  obturator  nerve.  Since  the  anterior  branch  of  this 
nerve,  after  supplying  the  gracilis,  adductor  longus,  and 
adductor  brevis  muscles  and  perforating  the  deep  fascia, 
furnishes  sensation  to  the  inner  side  of  the  thigh  as  low 
down  as  the  knee,  compression  of  this  nerve  causes  intense 
pain  and  sometimes  paresthesias  which  are  referred  to  the 
area  supplied  by  the  terminal  sensory  filaments.  A  glance 
at  the  inner  surface  of  the  anterior  pelvic  wall  in  a  case  in 
which  an  obturator  hernia  was  present  will  clearly  show 
the  relation  of  the  hernial  sac  to  the  obturator  nerve  (Fig. 
95). 

The  hip-joint  is  frequently  slightly  flexed  in  order  to 
relax  the  muscles,  and  any  attempt  to  change  this  position 
is  extremely  painful.  If  in  addition  to  this  symptom 
there  is  a  flat  sensitive  elevation  in  the  region  of  the 
pectineus  muscle  and  signs  of  intestinal  obstruction,  the 
presence  of  a  strangulated  obturator  hernia  may  be  inferred 
with  a  fair  degree  of  certainty.  Even  under  these  con- 
ditions the  diagnosis  is  not  absolutely  certain,  since  it  is 
possible  that  suppurations  proceeding  either  from  the  pelvis 
(Landerer)  or  from  the  peritoneum  (Kronlein)  may  pass 
outward  through  the  obturator  canal  and  even  simulate  the 
symptoms  of  intestinal  occlusion  by  irritating  the  perito- 
neum. An  obturator  hernia  may  be  differentiated  from  one 
of  the  femoral  variety  by  the  fact  that  it  is  situated  below 
and  internal  to  the  location  at  which  the  femoral  hernia 


234  HERNIA. 

Fig.  95. — A  frontal  section  through  the  pelvis  in  a  case  of  obturator 
hernia.  The  inner  surface  of  the  anterior  pelvic  wall  is  shown;  the 
entire  peritoneal  lining  has  been  removed  with  the  exception  of  the 
portion  surrounding  the  mouth  of  the  obturator  hernia.  The  hernial 
orifioe  is  below  and  to  the  inner  side  of  the  femoral  vein ;  the  obturator 
vessels  and  nerve  are  in  immediate  contact  with  the  neck  of  the  sac, 
being  situated  between  this  structure  and  the  transversalis  fascia, 
a,  deep  epigastric  artery ;  b,  spermatic  artery  and  vas  deferens;  c,  femo- 
ral artery;  d,  femoral  vein;  e,  Poupart's  ligament;  f,  urinary  bladder, 
g,  sac  of  the  obturator  hernia;  h,  obturator  nerve;  i,  obturator  vessels; 
k,  seminal  vesicle;  1,  rectum. 

usually  makes  its  appearance.  In  spite  of  all  these  signs, 
however,  there  are  cases  in  which  laparatomy  is  performed 
on  account  of  intestinal  obstruction,  and  the  presence  of  a 
strangulated  obturator  hernia  is  not  recognized  until  the 
time  of  operation. 


THE   TREATMENT   OF   OBTURATOR   HERNIA. 

Since  our  present  methods  do  not  enable  us  to  accurately 
diagnose  a  non-strangulated  obturator  hernia  in  a  larger 
percentage  of  individuals  than  formerly,  we  can  scarcely 
speak  of  a  radical  operation,  and  hardly  more  of  a  treat- 
ment by  means  of  a  truss.  It  will  consequently  suffice  if 
we  consider  the  treatment  of  strangulation  occurring  in  this 
region.  If  a  diagnosis  of  strangulated  obturator  hernia 
has  been  made,  or  if  there  is  a  suspicion  that  such  a  con- 
dition exists,  an  incision  should  be  made  in  the  anterior 
femoral  region  and  the  diagnosis  confirmed.  The  incision 
for  the  relief  of  the  constriction  should  be  nothing  more 
than  a  notch,  since  the  obturator  artery  always  lies  directly 
against  the  neck  of  the  sac,  usually  to  the  outer  side.  The 
hernial  canal  is  sometimes  so  narrow  that  the  strangulated 


Fig.  95. 


SCI  A  TIC  HERNIA .  235 

intestinal  coil  can  be  drawn  forward  only  with  difficulty 
and  shows  a  tendency  to  slip  back  into  the  abdominal 
cavity.  In  such  cases  it  is  best  to  open  the  abdomen  above 
Poupart's  ligament,  and  the  intestinal  coil  can  then  usually 
be  drawn  out,  thoroughly  inspected,  and  resected  if  neces- 
sary, the  peritoneal  cavity  being  previously  walled  off  by 
packing  sterile  gauze  about  the  gangrenous  intestine.  The 
operation  is  terminated  by  extirpating  the  hernial  sac  and, 
if  the  depth  of  the  wound  will  allow  it,  the  closure  of  the 
hernial  orifice  by  several  catgut  sutures. 

The  results  so  far  obtained  in  the  treatment  of  obturator 
hernia  cannot  be  said  to  be  satisfactory,  and  this  is  mainly 
due  to  the  difficulty  of  making  an  early  diagnosis.  In  105 
cases  of  obturator  hernia  collected  by  H.  Schmidt,  no  op- 
eration was  performed  in  62  patients ;  43  cases  were  op- 
erated upon  with  17  cures,  13  by  a  femoral  incision,  3  by 
laparotomy,  and  one  by  a  combination  of  the  two  methods. 
An  artificial  anus  was  made  in  4  cases,  all  ending  fatally ; 
intestinal  resection  was  necessary  in  5  cases,  one  of  these 
terminating  in  recovery. 

SCIATIC   HERNIA. 

The  extreme  rarity  of  this  variety  of  hernia  may  be 
seen  from  the  fact  that  Garre  was  able  to  collect  only  1 1 
undoubted  cases  observed  prior  to  1892.  It  is  true  that 
a  larger  number  of  cases  have  been  published  as  instances 
of  sciatic  hernia,  but  a  portion  of  these  must  be  excluded, 
since  they  were  really  perineal  hernias.  The  sciatic  hernia 
has  received  its  name  from  the  fact  that  it  passes  out  of  the 
pelvis  through  one  of  the  sciatic  foramina.     Figure  96 


236 


HERNIA. 


shows  a  lateral  view  of  the  pelvis  with  the  greater  and 
lesser  sacrosciatic  notches  and  the  lesser  and  greater  sacro- 
sciatlc  ligaments  which  respectively  convert  these  notches 
into  foramina. 


Fig,  96. — A  lateral  view  of  the  bony  pelvis:  a,  Great  sacrosciatic 
ligament;  b,  great  sacrosciatic  foramen;  c,  lesser  sacrosciatic  ligament; 
d,  lesser  sacrosciatic  foramen. 


The  larger  portion  of  the  great  sacrosciatic  foramen  is 
filled  by  the  pyriformis  muscle,  which  arises  from  the  inner 
surface  of  the  sacrum  and  is  inserted  into  the  trochanteric 
fossa  of  the  femur.  The  gluteal  artery  passes  out  through 
the  great  sacrosciatic  foramen  above  the  pyriformis,  while 


SCIA  TIC  HERNIA.  23 7 

the  sciatic  artery  and  nerve  emerge  through  the  same  for- 
amen, but  below  this  muscle  (Fig.  97).  The  lesser  sacro- 
sciatic  foramen  is  filled  by  the  obturator  internus  muscle, 
which  arises  from  the  inner  surface  of  the  obturator  mem- 
brane and  from  the  border  of  the  obturator  foramen,  passes 
out  through  the  lesser  sacrosciatic  foramen,  and  then  turns 
at  a  right  angle  to  be  inserted  into  the  trochanteric  fossa. 
A  sciatic  hernia  may  pass  out  from  the  pelvis  at  one  of 
three  places  :  (1)  Through  the  great  sacrosciatic  foramen 
alongside  of  the  gluteal  artery  (above  the  pyriformis) ; 
(2)  through  the  same  foramen  alongside  of  the  sciatic  artery 
(below  the  pyriformis) ;  (3)  through  the  lesser  sacrosciatic 
foramen.  According  to  Garre,  the  most  important  anatomic 
method  of  differentiating  a  sciatic  from  a  perineal  hernia 
is  by  its  position  above  the  great  sacrosciatic  ligament. 
Both  these  hernias  appear  externally  at  the  lower  border 
of  the  gluteus  maximus.  In  order  to  avoid  confusion, 
Garre  recommends  that  only  those  hernias  Avhich  pass  out 
through  the  lesser  sacrosciatic  foramen  should  be  designated 
as  sciatic  hernias,  while  the  other  two,  passing  through  the 
great  sacrosciatic  foramen  above  and  below  the  pyriformis, 
should  be  known  as  the  superior  and  inferior  gluteal  hernia 
respectively.  ^  Of  these  three  varieties,  the  superior  gluteal 
hernia  is  the  most  frequent,  and  an  ovary  has  been  found 
in  such  a  hernial  sac  in  three  instances. 

^  Translator's  Note. — This  classification  may  seem  confusino^  to 
the  English  mind,  but  its  apparent  complexity  may  be  readily  ex- 
plained by  the  differences  between  German  and  English  anatomic 
nomenclature.  The  gluteal  artery  of  English  and  American  works  is 
known  as  the  superior  gluteal  by  the  Germans,  while  the  sciatic 
artery  is  known  as  the  inferior  gluteal.  According  to  Garre's  classi- 
fication, the  superior  gluteal  hernia  passes  out  with  the  gluteal  artery, 
while  the  inferior  gluteal  hernia  follows  the  sciatic  artery. 


238  HERNIA. 

Fig.  97. — A  lateral  view  of  a  sciatic  hernia  (superior  gluteal 
hernia):  The  gluteus  maximus  muscle  has  been  divided  and  thrown 
back,  a  portion  of  the  gluteus  medius  has  been  removed,  and  the 
hernial  sac  has  been  opened,  exposing  an  intestinal  coil,  a,  Gluteus 
medius  muscle;  b,  gluteus  maximus  muscle;  c,  gluteal  artery  ;  d, 
gluteus  minimus  muscle;  e,  sciatic  hernia  (superior  gluteal  hernia); 
f,  pyriformis  muscle;  g,  sciatic  artery;  h,  great  trochanter;  i,  sciatic 
nerve.  The  three  muscular  bundles  situated  below  the  pyriformis 
are,  from  above  downward,  the  suj)erior  gemellus,  the  obturator 
internus,  and  the  inferior  gemellus. 

These  hernias  are  usually  small,  and  sometimes  so  insig- 
nificant in  size  that  no  external  swelling  is  visible.  The 
largest  sciatic  hernia  as  yet  observed  had  attained  the  size 
of  a  child's  head. 

Three  of  the  cases  collected  by  Garr^  had  undergone 
strangulation. 


PERINEAL  HERNIA. 

All  hernias  which  protrude  through  the  muscular  floor 
of  the  pelvis  toward  the  perineum  are  designated  as  perineal 
hernias,  and  receive  special  names  according  as  to  whether 
the  skin,  the  vagina,  or  the  rectum  is  pushed  in  advance 
of  the  hernial  protrusion. 

The  partition  between  the  peritoneal  cavity  and  the 
pelvic  outlet  is  formed  by  a  funnel-shaped  muscular  mass, 
which  passes  from  the  lateral  walls  of  the  pelvis  to  the 
lower  end  of  the  rectum  xmd  is  known  as  the  pelvic  dia- 
phragm. The  individual  muscles  forming  this  diaphragm 
are  the  coccygeus  and  the  pubic  and  iliac  portions  of  the 
levator  ani.  The  urogenital  tract  passes  through  the  pubic 
portion  of  the  levator  ani  muscle  and  a  narrow  slit  is  not 


Fig.  97. 


b 


PERINEAL  HERNIA.  230 

infrequently  found  between  the  iliac  portion  of  the  levator 
ani  and  the  coccygeus.  The  space  in  the  pubic  portion  of 
the  levator  ani  for  the  passage  of  the  urogenital  tract  is 
bridged  over  by  the  urogenital  diaphragm,  the  foundation 
of  which  is  the  deep  transverse  perineal  muscle.  The 
upper  and  lower  surfaces  of  the  pelvic  diaphragm  are  cov- 
ered by  the  superior  and  inferior  fascias  of  the  pelvic  dia- 
phragm respectively.  The  space  below  the  pelvic  dia- 
phragm, between  it,  the  skin  of  the  perineum,  and  the 
tuberosity  of  the  ischium,  is  known  as  the  ischiorectal 
fossa,  and  is  filled  with  loose  areolar  tissue  about  the  lower 
end  of  the  rectum.  Every  perineal  hernia  must  pass 
through  the  pelvic  diaphragm,  either  between  the  coccygeus 
and  the  levator  ani  muscles  or  between  the  fibers  of  the 
levator  ani.  The  hernia  then  passes  downward  in  the 
ischiorectal  fossa  (Fig.  98)  until  it  causes  a  protrusion  of 
the  skin  of  the  perineum  (perineal  hernia).  The  hernia 
may  protrude  toward  the  rectum  (^rectal  hernia),  toAvard 
the  vagina  (vaginal  hernia),  or  toward  the  posterior  portion 
of  the  labium  majus  (^pudendal  hernia). 

According  to  Ebner,  who  published  a  monograph  upon 
perineal  hernia  in  1887,  the  main  requisite  for  the  devel- 
opment of  this  variety  is  a  congenital  low  position  of  the 
peritoneal  fold  in  the  space  of  Douglas — the  recto-vesical 
fold  in  the  male,  the  recto-uterine  fold  in  the  female. 
Although  the  opposite  opinion  is  held  by  certain  authori- 
ties, Ebner  denies  that  a  laceration  of  the  perineal  muscles 
by  an  injury,  such  as  a  fall  from  a  height,  can  exert  any 
influence  upon  the  development  of  this  hernia.  '^  A 
trauma  or  gross  mechanical  lesion  is  no  more  able  to  pro- 
duce a  perineal  hernia  than  is  a  fissure  in  the  levator  ani 


240  HERNIA. 

Fig.  98. — Diagrammatic  frontal  section  through  the  pelvis,  exposing 
the  rectum  (a).  The  i)elvic  diaphragm  (b)  is  seen  jmssing  from  the 
inner  surface  of  the  true  pelvis  to  the  lower  end  of  the  rectum.  This 
diaphragm  is  perforated  on  one  side  by  the  protrusion  of  a  hernial  sac 
which  is  still  situated  within  the  ischiorectal  fossa,  a,  Kectum;  b, 
pelvic  diaphragm;  c,  parietal  i:>eritoneum;  d,  sac  of  a  perineal  hernia. 


alone ;  a  congenital  or  pre-existing  peritoneal  fold  is  nec- 
essary in  all  cases.  If  a  mechanical  lesion  occurs,  it  may 
cause  either  a  separation  of  the  pre-existing  fissure  in  the 
levator  ani,  allowing  the  intestine,  which  already  rests 
upon  the  pelvic  floor  to  protrude,  or  it  causes  the  hernial 
sac,  which  has  already  protruded  through  the  levator  ani, 
to  become  filled  with  intestinal  coils."  At  all  events,  it 
will  consequently  be  seen  that  such  an  accident  may  exert 
a  deleterious  influence  upon  the  hernia. 

A  perineal  hernia  may  appear  in  any  of  the  following 
forms  : 

1.  In  the  male  the  hernia  descends  between  the  blad- 
der and  the  rectum  and  causes  a  protrusion  of  the  skin  of 
the  perineum. 

In  the  female  the  hernia  develops  between  the  uterus 
and  the  rectum,  and  appears  either  near  the  anus  or  in  the 
posterior  portion  of  one  of  the  labia  majora.  Such  hernias 
appearing  between  the  anus  and  the  tuberosity  of  the 
ischium  will  consequently  protrude  externally,  like  a  sciatic 
hernia,  below  the  lower  border  of  the  gluteus  maximus. 

2.  The  hernia  protrudes  toward  the  rectum  or  vagina 
and  pushes  one  of  these  structures  in  advance  of  it,  so  that 
a  prolapse  of  the  organ  occurs  (the  prolapse  hernia  of 
Rose).  In  this  manner  a  rectal  hernia  (Fig.  99)  or  a 
posterior  vaginal  hernia  may  arise. 


Fig.  OS. 


PERINEA  L  HERNIA . 


241 


a-i- 


b 


Fig.  99. — A  semi-diagrammatic  sagittal  section  of  a  male  pelvis 
revealing  a  perineal  hernia  (a  prolapse  hernia  of  the  rectum).  The 
prolapsed  rectum  (a)  has  been  partl}^  cut  open  and  the  recto-vesical 
space  has  been  distended  by  the  downward  protrusion  of  a  large 
hernial  sac  (b)  which  contains  a  convolution  of  intestinal  coils. 


16 


242  HERNIA. 

3.  In  the  female  the  peritoneal  protrusion  may  occur 
in  the  space  between  the  uterus  and  the  bladder,  so  that  a 
prolapse  hernia  of  the  anterior  vaginal  wall  (anterior 
vaginal  hernia)  is  produced. 

In  addition  to  these  completely  developed  forms  of 
perineal  hernia,  incomplete  forms  also  occur,  since  the 
hernia  may  remain  in  the  ischiorectal  fossa  or  protrude 
toward  the  bladder  without  causing  a  visible  external 
swelling.  Hernias  are  also  observed  in  the  perineal 
region  which  protrude  through  the  scars  resulting  from  the 
sacral  operation  for  the  removal  of  the  rectum ;  these  are 
called  sacral  hernias  by  Hochenegg,  who  has  described 
several  such  cases. 

A  perineal  hernia  may  attain  a  considerable  size. 
Hager,  for  example,  described  one  case,  the  hernia  pro- 
truding alongside  of  the  rectum,  the  longitudinal  diameter 
of  which  was  about  48  centimeters,  while  the  greatest 
transverse  diameter  was  about  24  centimeters.  Hernias 
of  such  dimensions  are,  of  course,  extremely  rare. 

The  diagnosis  of  perineal  hernia  is  of  great  practical 
importance,  for  it  is  clear  that  disastrous  consequences 
must  ensue  if  such  an  apparently  harmless  rectal  or  vaginal 
prolapse  is  supposed  to  be  due  to  an  abscess  or  to  a  polyp. 
It  has  happened  that  such  cases  have  been  either  incised 
or  ligated,  according  to  the  nature  of  the  supposition,  and 
the  intestine  has  either  been  opened  or  completely  con- 
stricted by  a  ligature.  In  addition  to  a  careful  considera- 
tion of  the  general  symptoms  of  hernia,  the  presence  of  a 
gurgling  murmur  upon  reduction  should  be  particularly 
sought  for  as  a  sign  of  the  presence  of  an  intestinal  coil. 

The  performance  of  the  radical  operation  is  made  most 


INGUINO-PEBINEAL  HERNIA.  243 

difficult  by  the  deep  position  of  the  hernial  orifice  and  by 
the  relaxation  of  the  pelvic  diaphragm.  Records  of  such 
operations  are  extremely  scanty  at  the  present  time. 


[INGUINO-PERINEAL  HERNIA. 

There  is  another  variety  of  hernia,  which  Sultan  does 
not  mention,  and  which,  in  fact,  is  seldom  described  in  any 
of  the  text-books  on  hernia — namely,  inguino-perineal 
hernia.  This  name  I  have  used  in  describing  a  hernia 
associated  with  mal-descent  of  the  testis.  I  have  observed 
six  cases  of  testis  in  the  perineum,  in  four  of  which  there 
was  an  associated  well-developed  hernia,  the  latter  follow- 
ing the  course  of  the  testis  and  appearing  in  the  perineum 
rather  than  in  the  scrotum.  In  one  of  these  cases  which 
I  have  reported,  the  hernia  was  the  size  of  a  cocoanut  and 
the  testis  very  small  and  ill  developed.  In  this  case  the 
testis,  together  with  the  entire  pouch,  consisting  of  sac  and 
skin,  were  removed  and  the  wound  closed  in  three  layers. 
The  patient  remained  well  for  three  years  and  then  death 
resulted  from  drowning.  In  the  other  three  cases  the 
testes  were  apparently  fully  developed,  and  in  these  cases, 
by  preserving  a  sufficient  amount  of  peritoneum,  it  was 
possible  to  make  a  perfect  tunica  vaginalis.  I  then  formed 
a  new  pouch  with  the  finger  in  the  hitherto  empty  scrotum, 
into  which  the  testis  with  its  new  tunica  was  transplanted. 
The  patients  made  a  good  recovery  and  have  remained 
well  up  to  the  present  time. — Ed.] 


244  HERNIA. 

DIAPHRAGMATIC  HERNIA. 

Strictly  speaking,  the  majority  of  the  so-called  diaphrag- 
matic hernias  shonld  not  be  designated  as  such  if  we 
adhere  to  our  original  definition,  according  to  which  every 
abdominal  hernia  must  have  a  sac.  The  detailed  collec- 
tions of  cases  given  us  by  Lacher  (1880),  Thoma  (1882), 
and  Grosser  (1899)  show  that  the  great  majority  of  these 
so-called  hernias  have  no  sacs ;  in  Grosser's  collection  of 
433  cases,  for  example,  only  40  had  sacs.  The  diaphrag- 
matic hernias  diflPer  from  ordinary  hernias  in  still  another 
respect,  since  they  are  congenital  in  the  majority  of  cases 
and  are  dependent  upon  an  arrested  development  of  the 
diaf)hragm.  We  may  consequently  differentiate  the  fol- 
lowing varieties  : 

True  diaphragmatic  hernia  (with  a  sac) ; 

False  ^'  "       (without  a  sac) ; 

Congenital  "  "       (true  or  false) ; 

Acquired  "  "       (true  or  false). 

According  to  Cruveilhier,  whose  view  is  supported  by 
Thoma,  another  pathologic  condition,  usually  designated 
as  diaphragmatic  hernia,  would  be  better  described  by  the 
term  ^'diaphragmatic  eventration."  This  is  produced  by 
a  marked  protrusion  of  the  attenuated  left  half  of  the  dia- 
phragm into  the  left  thoracic  cavity.  "  In  this  manner  a 
sac  is  formed  consisting  practically  of  connective  tissue, 
which  fills  a  large  part  of  the  thoracic  cavity  and  looks  not 
unlike  an  actual  hernial  sac''  (Thoma). 

The  diaphragmatic  hernia  mostly  affects  the  left  side, 


DIAPHRAGMATIC  HERNIA.  245 

probably  because  the  liver  furnishes  a  protection  for  the 
right  side  of  the  diaphragm. 

In  order  to  become  acquainted  with  the  situations  in 
which  the  hernias  of  the  diaphragm  usually  protrude  we 
must  briefly  review  the  normal  structure  of  the  inferior 
surface  of  the  diaphragm  (Fig.  100). 

The  diaphragm  is  composed  of  three  muscular  portions, — 
the  sternal,  costal,  and  lumbar, — which  are  united  by  a 
central  fibrous  plate,  the  central  tendon.  A  narrow  fissure 
exists  between  the  sternal  and  costal  portions  (Fig.  100,  b), 
and  there  is  a  second  one  of  varying  size  located  between 
the  costal  and  lumbar  portions  (Fig.  100,  h).  The  lumbar 
portion  of  each  side  is  composed  of  three  crura — an  internal, 
an  intermediate,  and  an  external.  The  aortic  opening  lies 
between  the  internal  crura  of  the  lumbar  portions,  that  for 
the  esophagus  is  embraced  by  the  same  crura,  while  that 
for  the  vena  cava  is  situated  in  the  rioht  half  of  the  central 
tendon.  The  sympathetic  trunk  passes  between  the  ex- 
ternal and  intermediate  crura  of  the  pars  lumbalis. 

Disregarding  the  cases  in  which  the  entire  diaphragm 
or  its  tendinous  center  are  Avanting,  hernial  orifices  have 
been  observed  in  the  following  situations,  w^iich  are  given 
in  the  order  of  their  frequency  :  (1)  Central  tendon  ;  (2) 
the  muscular  portion,  particularly  in  the  posterior  inferior 
portions ;  (3)  the  fissure  situated  between  the  sternal  and 
costal  portions  ;  (4)  the  esophageal  opening  ;  (5)  the  fissure 
situated  between  the  lumbar  and  costal  portions ;  (6)  the 
point  of  passage  of  the  sympathetic  trunk. 

From  Avhat  has  been  said,  the  following  possibilities 
must  be  borne  in  mind  in  considering  the  development  of 
a  diaphragmatic  hernia.     A  congenital  defect  in  the  dia- 


246 


HERNIA. 


Fig.  100. — A  view  of  the  inferior  surface  of  the  diaphragm  :  a, 
Sternal  portion  ;  b,  fissure  between  the  sternal  and  costal  jjortions ; 
c,  costal  portion  ;  d,  central  tendon  ;  e,  inferior  vena  cava  ;  f,  esoph- 
agus ;  g,  lumbar  portion  ;  h,  fissure  between  the  lumlmr  and  costal 
portions  ;  i,  aorta  ;  k,  psoas  muscle  ;  1,  quadratus  lumborum  muscle  ; 
m,  sympathetic  trunk. 


phragm  may  exist  and  the  abdominal  viscera  are  situated 
within  the  thoracic  cavity  at  birth  or  enter  it  during  extra- 
uterine life  ;  a  hernia  acquired  later  in  life  may  pass  through 
one  of  the  previously  mentioned  fissures,  probably  favored 
by  a  traumatism  which  has  led  to  a  dilatation  of  one  of 
these  fissures.  Still  another  possibility  is  furnished  by  in- 
juries of  the  diaphragm  from  punctured  or  gunshot  wounds 
or  even  from  a  contusion  ;  if  the  diaphragm  is  completely 
perforated,  a  diaphragmatic  hernia  without  a  sac  results, 
while  if  it  is  only  penetrated,  so  that  the  parietal  peritoneum 
remains  intact,  the  diaphragmatic  hernia  is  provided  with 
a  sac.  The  following  figures,  furnished  by  the  collections 
of  Thoma  and  Grosser,  give  an  idea  of  the  relative  fre- 
quencies of  the  different  varieties  of  diaphragmatic  hernia. 
Of  433  diaphragmatic  hernias  there  were  : 


Congenital  Hern 

IAS. 

Acquired 

Hernias. 

True  Hernias. 

Eveutiations. 

False  Hernias. 

True. 

False. 

Right. 

Left. 

Left. 

Right. 
33 

Left. 

10 

10 

20 

8 

l.'^l 

171 

In  spite  of  the  considerable  number  of  diaphragmatic 
hernias  which  have  been  reported,  tlie  diagnosis  has  been 
made  in  the  living  scarcely  more  than  six  times.     Leichten- 


Fig.  100. 


DIAPHRAGMATIC  HERNIA.  247 

stern  diagnosed  one  case  correctly,  and  quite  recently  Hirsch 
had  a  case  in  which  the  diagnosis  made  by  a  physical  ex- 
amination was  confirmed  by  skiagraphy  in  a  most  interesting 
manner. 

As  the  stomach  is  very  frequently  displaced  into  the 
thoracic  cavity,  gastric  disturbances  play  the  chief  role  in 
the  symptom-complex.  The  patients  complain  of  gastric 
pains  which  appear  after  eating  and  radiate  to  the  thoracic 
region.  These  attacks  of  pain  alternate  with  periods  of 
comparative  good  health,  and  are  to  be  partly  referred  to 
the  temporary  occurrence  of  strangulation. 

A  clear  note  like  that  of  intestinal  tympany  may  be 
demonstrated  by  percussing  the  affected  half  of  the  thorax, 
and  is  particularly  distinct  if  the  stomach  is  inflated  or  if 
air  is  pumped  into  the  intestine  through  the  anus.  Accord- 
ing to  Hirsch,  a  high  position  of  the  diaphragm  may  be 
excluded  by  the  more  marked  protrusion  of  the  affected 
side  of  the  chest.  In  the  ordinary  left-sided  diaphrag- 
matic hernia,  the  displacement  of  the  heart  to  the  right  is 
so  characteristic  that  the  possibility  of  the  existence  of  a 
diaphragmatic  hernia  should  be  borne  in  mind  in  every 
case  of  isolated  dextrocardia.  The  more  viscera  in  the 
thoracic  cavity,  the  greater  the  compression  exerted  upon 
the  heart  and  lungs  ;  and  in  those  hernias  which  develop 
suddenly,  particularly  the  traumatic  variety,  death  may 
occur  at  once  or  very  quickly,  being  preceded  by  symp- 
toms of  violent  dyspnea  and  marked  cyanosis.  Under 
certain  circmnstances,  individuals  with  diaphragmatic 
hernias  may  reach  an  advanced  age,  l;)ut  they  are  always 
in  danger  of  having  a  strangulation  from  any  kind  of 
excessive  exertion. 


Fig.  101.— A  newborn  child  with  a  true  left-sided  congenital  dia- 
phragmatic hernia.  At  the  autopsy,  performed  at  tlie  Pathologic 
Institute  at  Gottingen,  the  hernial  sac,  which  was  half  the  size  of  a 
fist,  was  found  to  contain  the  stomach,  the  spleen,  and  the  greater  por- 
tion of  the  small  intestine.  A  finger  could  be  comfortably  passed 
through  the  defect  in  the  diaphragm,  which  was  situated  about  1^ 
centimeters  to  the  left  of  the  esophageal  opening.  The  cecum  and 
vermiform  process  were  found  at  the  left  side  of  the  vertebral  column 
covering  the  left  kidney. 

248 


Fig.  102.  — A  newborn  child  with  a  false  left-sided  congenital  dia- 
phragmatic hernia.  The  defect  involved  the  posterior  and  inferior 
part  of  the  left  half  of  the  diaphragm  and  was  limited  to  the  muscular 
portion.  It  was  circular  in  shape,  had  a  smooth  edge,  and  was  about 
2|  centimeters  in  diameter.  The  hernial  contents  consisted  of  the 
liver,  all  of  the  small  intestine,  and  the  greater  portion  of  the  large 
intestine  with  the  cecum  and  vermiform  process. 


249 


250  HERNIA. 

In  addition  to  the  stomach  and  colon,  omentum,  small 
intestine,  liver,  duodenum,  pancreas,  spleen,  and  kidney 
have  also  been  found  as  contents  of  a  diaphragmatic 
hernia. 

Up  to  the  present  time,  treatment  has  been  instituted 
only  in  strangulated  diaphragmatic  hernias.  Under  such 
conditions  a  laparotomy  has  been  performed,  the  viscera 
drawn  back  into  the  abdominal  cavity,  and  an  occasional 
recovery  obtained.  It  has  repeatedly  happened,  however, 
that  the  strangulated  diaphragmatic  hernia  has  not  been 
found  in  spite  of  the  performance  of  laparotomy.  If  the 
diagnosis  of  a  strangulated  diaphragmatic  hernia  has  been 
surely  made,  Perman  suggests  the  exposure  of  the  hernial 
orifice  in  the  pleural  cavity  by  making  a  horseshoe  flap  out 
of  the  thoracic  wall ;  sufficient  space  may  be  obtained  by 
resecting  the  ribs  to  allow  of  thorough  inspection,  reduction 
of  the  hernia,  and  suture  of  the  hernial  orifice.  To  the 
best  of  my  knowledge,  this  suggestion  has  not  yet  been 
practically  tested. 


VENTRAL  HERNIA, 

All  of  the  hernias  appearing  on  the  anterior  abdominal 
wall,  with  the  exception  of  the  umbilical  and  the  inguinal, 
are  designated  as  ventral  hernias,  and  these  are  subdivided 
into  the  median  ventral  hernia,  or  hernia  of  thelinea  alba, 
and  the  lateral  ventral  hernia. 

HERNIA   OF   THE   LINEA  ALBA. 
Although  the  importance  of  this  variety  of  hernia,  first 
described  by  Garengeot  (1743),  and  made  the  subject  of  an 


VENTRAL  HERNIA.  251 

excellent  description  by  A.  G.  Richter,  of  Gottingen 
(1785),  was  early  recognized,  it  did  not  receive  general 
attention  until  daring  the  last  twenty  or  thirty  years.  The 
description  of  these  hernias  is  inseparably  connected  with 
a  consideration  of  the  subperitoneal  lipomas,  which  show  a 
marked  predilection  for  this  location,  because  they  may 
easily  be  mistaken  for  hernias  and  because  both  a  hernia  and 
a  lipoma  may  coexist  in  this  situation.  These  hernias  are 
far  more  commonly  observed  above  the  umbilicus,  midway 
between  it  and  the  xiphoid  process,  than  below  the  umbilicus, 
and  this  is  due  to  the  anatomic  structure  of  the  linea  alba, 
which  is  formed  by  the  union  of  the  layers  of  aponeurosis 
in  the  median  line  of  the  body.  The  connective-tissue 
fibers  from  both  sides  interlace  and  form  a  dense  network 
with  lozenge-shaped  interstices.  The  linea  alba  which  is 
thus  formed  becomes  broader  as  it  passes  from  the  xiphoid 
cartilage  to  the  umbilicus,  and  is  rather  thin  in  this  situa- 
tion, while  below  the  umbilicus  it  becomes  narrower  and 
at  the  same  time  increases  in  thickness.  The  hernias 
appearing  above  the  navel  are  also  known  as  epigastric 
hernias.  Those  hernias  which  occur  immediately  to  one 
side  of  the  median  line  are  also  included  under  the  desig- 
nation of  hernias  of  the  linea  alba,  since  they  do  not 
exhibit  any  clinical  differences  from  this  variety.  The 
frequency  of  epigastric  hernia  is  shown  by  the  statistics  of 
Berger:  In  10,000  patients  with  hernia  he  found  137  of 
the  epigastric  variety;  117  of  these  were  in  males  over 
fifteen  years  of  age,  1 2  were  in  females  of  the  same  age, 
and  3  were  in  boys  and  5  in  girls  who  were  under  fifteen 
years  of  age. 

It  has  previously   been  mentioned    that    subperitoneal 


252 


HERNIA. 


lipomas  (Fig.  103)  are  of  frequent  occurrence  in  this  situ- 
ation. The  exact  ratio  which  they  hold  to  true  hernias 
may  be  learned  from  the  series  of  cases  collected  by 
Ploger,  who  found  that  in  77  so-called  epigastric  hernias 
only  46  were  true  hernias,  the  remaining  31  cases  being 
lipomas.  The  lipomas  vary  in  size  from  that  of  a  pea  to 
that  of  a  hen's  ^ggy  although  they  rarely  attain  the  latter 


Fig.  103. — A  subperitoneal  lipoma  resembling  an  epigastric  hernia 
situated  midway  between  the  umbilicus  and  the  xiphoid  cartilage. 


dimensions  (see  also  Fig.  42).  The  fissure  in  the  linea  alba 
through  which  the  lipomas  protrude  is  almost  always  trans- 
verse ;  this  is  best  observed  in  small  lipomas,  since  the 
increasing  size  of  the  tumor  must  cause  the  orifice  to  dilate 
and  assume  a  more  or  less  circular  outline  (Fig.  16).  It 
occasionally  happens  that  several  such  lipomas  are  situated 
one  above  the  other.  The  diastasis  of  the  recti  muscles 
which  is  not  infrequently  encountered  has  no  more  to  do 


VENTRAL  HERNIA.  253 

with  an  actual  hernia  than  has  the  supra-umbilical  even- 
tration ^  which  was  repeatedly  found  in  children  l)y  Ber- 
ger,  and  we  may  consequently  omit  its  consideration. 

It  was  formerly  supposed  that  the  stomach  was  very 
frequently  found  within  the  true  hernias,  since  the  patients 
complain  particularly  of  gastric  disturbances  and  because 
the  tumor  is  usually  situated  in  the  gastric  region,  but  we 
have  previously  learned  (pages  44  and  48)  that  these  dis- 
turbances may  be  reflexly  produced  by  traction  upon  the 
peritoneum.  As  a  matter  of  fact,  there  are  only  a  few  cases 
in  the  literature  in  which  the  stomach  has  been  certainly 
demonstrated  as  the  contents  of  such  a  hernia  ;  the  hernial 
sac  usually  contains  omentum  and,  more  rarely,  a  coil  of 
small  or  large  intestine.  If  the  hernial  sac  is  empty,  it  is 
usually  very  small  and  connected  with  a  subperitoneal 
lipoma. 

Figures  104  and  105  illustrate  a  particularly  rare  case 
of  strangulated  epigastric  hernia.  The  hernial  protrusion, 
almost  as  large  as  a  man's  head,  was  situated  above  the  um- 
bilicus somewhat  to  the  right  of  the  median  line.  All  the 
signs  of  strangulation  were  present,  and  at  the  herniotomy 
the  sac  was  found  to  contain  strangulated  omentum  in  which 
a  malignant  tumor  was  present. 

In  very  rare  cases  congenital  apertures  in  the  linea  alba 
may  have  something  to  do  with  the  development  of  epigas- 
tric hernias  (Cooper),  and  it  may  be  said  in  a  general  way 
that  the  same  causes  which  are  active  in  the  formation  of 

^  "  Supra-umbilical  eventration  is  characterized  by  the  protrusion  of 
the  supra-umbilical  peritoneum  and  the  abdominal  viscera  through 
the  interspace  between  the  recti  muscles  when  the  child  cries  or  when 
it  flexes  the  thighs  upon  the  abdomen  "  (Berger). 


254 


HERNIA, 


^»'""  "V"*.' 


Fig.  104. 


Fig.  105. 


VENTRAL  HERNIA.  255 

Fig.  104. — Anterior  view  of  a  patient  with  a  strangulated  epigastric 
hernia. 

Fig.  105. — A  lateral  view  of  the  same  patient.  The  patient  was 
fifty-one  years  of  age  and  for  the  past  eight  years  had  had  an  irrednci- 
ble  epigastric  hernia  as  large  as  a  goose-egg.  Six  days  before  her 
admission  to  the  surgical  clinic  at  Gottingen  the  hernia  suddenly  in- 
creased in  size  and  caused  violent  pain.  Since  this  time  absolute  con- 
stipation existed  and  there  was  frequent  vomiting. 

The  examination  of  the  unfortunate  woman  revealed  a  tumor  imme- 
diately above  the  umbilicus,  almost  as  large  as  a  man's  head,  which 
extended  on  both  sides  of  the  median  line  and  particularly  toward  the 
right  side.  The  overlying  skin  was  red,  thickened,  and  adherent. 
The  tumor  was  very  sensitive  to  pressure  and  gave  a  dull  note  upon  per- 
cussion. The  umbilicus  was  unchanged  and  situated  ui)on  the  left 
side  of  the  inferior  surface  of  the  tumor. 

At  the  operation,  which  was  immediately  performed,  the  incision 
into  the  hernial  sac  gave  exit  to  a  bloody  hernial  fluid  and  exposed  a 
large  mass  of  abnormal  omentum.  After  the  hernial  orifice,  which 
was  five  centimeters  (two  inches)  in  diameter,  had  been  enlarged  by 
an  incision  the  omentum  was  ligated  in  sections  and  extirpated.  The 
sac  was  also  removed  and  the  abdominal  wound  closed  with  inter- 
rupted silk  sutures,  which  were  passed  through  all  the  layers  of  the 
abdominal  wall. 

Microscopic  examination  showed  that  the  extirpated  mass  was  a 
malignant  omental  tumor,  partly  of  alveolar  structure,  which  had 
originated  in  the  peritoneal  endothelium. 


other  hernias  must  exert  an  influence  in  the  development 
of  this  variety.  A  particular  influence  is  assigned  to 
trauma  by  many,  and  in  certain  cases  this  cannot  be  denied. 
It  is  questionable  whether  a  single  trauma  can  ever  form 
a  hernial  sac.  It  is  much  more  probable  that  a  small,  un- 
recognized lipoma  draws  the  peritoneum  out  into  a  funnel- 
shaped  diverticulum  so  that  the  hernial  sac  is  already 
formed  when  the  traumatism  occurs.  It  will  be  readily 
understood  that  such  a  pre-existing  sac  may  suddenly  be- 


256  HERNIA. 

Fig.  106. — Multiple  lateral  ventral  hernias.  This  patient  was 
thirty-nine  years  of  age  and  had  borne  five  children  without  exhibiting 
any  abnormality  of  the  abdominal  wall.  At  about  the  fourth  or  fifth 
month  of  the  sixth  pregnancy  she  fell  and  struck  her  abdomen  against 
a  pile  of  rubbish.  Soon  after  this  accident  she  noticed  the  appearance 
of  an  umbilical  hernia.  After  the  birth  of  the  sixth  child  the  um- 
bilical hernia  gradually  enlarged  ;  it  was  no  longer  reducible  and  was 
finally  operated  upon.  About  eight  weeks  later  she  caught  cold,  and 
the  coughing  caused  a  new  hernial  protrusion  above  the  scar  resulting 
from  the  operation.  She  was  then  operated  upon  a  second  time.  She 
again  became  pregnant,  and  during  and  after  this  pregnancy  other 
hernias  developed  at  several  locations  in  the  abdominal  wall. 

When  the  patient  was  examined  at  the  surgical  clinic  at  Gottingen, 
she  had  a  most  marked  pendulous  abdomen  and  a  linear  operative  scar 
which  commenced  above  the  umbilicus  and  extended  downward  in  the 
median  line  for  a  distance  of  12  centimeters  (4|  inches).  In  addition 
to  a  diffuse  protrusion  of  the  u]3per  portion  of  the  operative  scar  and 
of  the  region  immediately  above  it,  three  sharply  circumscribed  lateral 
ventral  hernias  were  observed.  The  first  of  these  was  as  large  as  a 
child's  head  and  situated  upon  the  right  side  ;  its  contents  could  be 
reduced,  a  gurgling  murmur  being  heard  at  the  time  of  reduction,  and 
three  or  four  fingers  could  be  comfortably  introduced  into  the  hernial 
orifice.  The  second  hernia  was  below,  and  the  third  to  the  left  of  the 
operative  scar.  The  latter  two  hernias  were  only  half  as  large  as  the 
first  ;  they  were  readily  reducible  and  their  hernial  orifices  were  large 
enough  to  admit  one  or  two  fingers. 

come  enlarged  and  filled  with  viscera  by  an  injury  which 
produces  an  excessive  tension  of  the  anterior  abdominal 
wall  and,  at  the  same  time,  a  violent  augmentation  of  the 
intra-abdominal  tension.  It  is  worthy  of  note  that  the 
epigastric  hernias  developing  without  preceding  injury  are 
usually  observed  in  strong  healthy  men  in  the  prime  of 
life  who  do  the  heaviest  kind  of  work.  Volckers  has  re- 
cently laid  particular  stress  upon  this  fact,  and  regards  the 
strenuous  occupation  as  the  chief  cause  of  development  of 
such  hernias.     The  continuous  heavy  work  is  supposed  to 


VENTRAL  HERNIA. 


257 


Fig.  106. 


17 


258  HERNIA. 

Fig.  107. — Hernia  of  a  scar  after  laparotomy.  This  patient  was 
twenty -four  years  of  age  and  had  had  her  vermiform  process  removed 
on  account  of  recurring  attacks  of  appendicitis.  Al)Out  six  months 
later  three  small  hernias  developed  at  the  sites  of  the  stitch-holes  ; 
they  varied  in  size  from  that  of  a  hazelnut  to  that  of  a  walnut,  two 
being  to  the  right  and  one  to  the  left  of  the  operative  scar. 


act  as  a  series  of  slight  traumatisms,  by  Avbich  the  sol- 
idity of  the  linea  alba  is  impaired  until  one  of  its  meshes 
is  sufficiently  dilated  to  allow  of  a  protrusion  of  peritoneum 
or  of  the  escape  of  a  small  subperitoneal  lipoma. 

A  hernia  of  the  linea  alba  sometimes  causes  indefinite 
dragging  abdominal  pain,  which,  though  occasionally  re- 
ferred to  no  particular  abdominal  organ,  is  more  often 
definitely  localized  in  the  gastric  region.  This  symptom  is 
usually  designated  by  the  patient  as  "  a  pressure  in  the  pit 
of  the  stomacli,'^  but  it  may  be  so  severe  that  they  speak 
of  "  violent  cramps  in  the  stomach.''  Anorexia,  eructation, 
and  vomiting  are  also  frequently  observed.  All  of  these 
symptoms  may  be  concomitant  with  and  yet  not  dependent 
upon  the  presence  of  a  hernia  of  the  linea  alba  or  of  a  sub- 
peritoneal lipoma.  It  frequently  happens  that  a  subperi- 
toneal lipoma  is  found  by  chance  in  individuals  to  whom 
it  does  not  cause  the  slightest  inconvenience.  A  most  care- 
ful examination  of  the  stomach  should  be  made  in  all  such 
cases,  however,  since  it  is  possible  that  the  symptoms  are 
due  to  a  graver  disease,  and  that  the  subperitoneal  lipoma 
is  only  an  accidental  and  irrelevant  concomitant. 

The  radical  operation  is  practically  the  only  treatment 
to  be  considered,  since  completely  reducible  hernias  of  the 
linea  alba  are  very  rare,  and  because  it  is  most  difficult  to 
construct  and  apply  a  truss  that  will  not  become  displaced. 


VENTRAL  HERNIA. 


259 


Fig.  107. 


260  HERNIA. 

Fig.  108. — Petit's  triangle  and  Braun's  space  :  a,  Latissimus  dorsi 
muscle  ;  b,  external  oblique  muscle;  c,  Braun's  space  ;  d,  Petit's  tri- 
angle ;  e,  gluteus  maximus  muscle.  Upon  the  left  side  there  was  also 
an  opening  analogous  to  the  one  upon  the  right  (c).  This  left-sided 
opening  gave  passage  to  a  lumbar  hernia,  while  the  one  upon  the  right 
side  was  empty. 

Even  though  the  case  is  apparently  nothing  more  than  a 
simple  subperitoneal  lipoma,  it  is  always  best  to  open  the 
abdominal  cavity,  since  this  is  the  only  certain  method  of 
determining  whether  the  lipoma  has  a  small  hernial  sac 
behind  it  in  which  a  tip  of  omentum  may  be  adherent. 
If  such  a  condition  should  exist,  the  symptoms  will  not 
disappear  until  the  adhesion  has  been  broken  up  or  the 
piece  of  omentum  ligated.  The  operation  is  completed  by' 
the  exact  closure  of  the  abdominal  wound,  which  is  best 
attained  by  passing  the  sutures  through  all  the  layers  of 
the  abdominal  wall. 

If  the  lipoma  is  extirpated  without  opening  the  abdom- 
inal cavity,  the  edges  of  the  transverse  slit  in  the  linea 
alba  should  be  approximated  with  one  or  more  sutures 
before  the  cutaneous  wound  is  closed. 

LATERAL  VENTRAL  HERNIA. 
A  lateral  ventral  hernia  may  appear  at  any  situation  in 
the  lateral  abdominal  wall,  but  it  nevertheless  has  its  seats 
of  predilection.  One  of  these  is  at  the  semilunar  line 
(I'lnea  semicircularh  Spigelu)  which  marks  the  insertion  of 
the  transversalis  muscle  into  its  aponeurosis  (Fig.  5). 
These  hernias  most  frequently  appear  between  this  line 
and  the  outer  border  of  the  rectus  muscle  (Fig.  106). 
Next  in  order  of  frequency  is  the  lateral   region  of  the 


Fifj.  lOS. 


VENTRAL  HERNIA.  261 

abdomen,  and  in  very  rare  instances  these  hernias  have 
been  observed  to  the  outer  side  of  the  semihmar  line  or  in 
the  lower  portion  of  the  aponeuroses  of  the  oblique 
muscles. 

The  most  important  factor  in  the  development  of  lateral 
ventral  hernias  is  the  marked  distention  of  the  abdominal 
wall  which  may  be  produced  by  repeated  pregnancies,  by 
ascites,  and  by  rapid  emaciation  in  very  obese  individuals. 
Traumatisms  which  have  produced  a  subcutaneous  lacera- 
tion of  the  muscles  may  lead  to  tlie  formation  of  hernias, 
as  may  also  the  distention  of  the  scars  which  result  from 
perforating  wounds  of  the  abdominal  wall  or  from  opera- 
tions (Fig.  107). 

Strangulation  is  occasionally  observed  in  lateral  ventral 
hernias,  but  it  does  not  difPer  from  strangulation  occurring 
in  other  situations. 

The  operative  treatment  of  large  ventral  hernias  prom- 
ises but  little,  since  the  causes  which  led  to  the  devel- 
opment of  the  hernia  are  equally  active  after  the  operation. 
The  conditions  are  different  in  the  moderate-sized  hernias 
of  scars  in  young  individuals.  In  the  majority  of  such 
cases  a  permanent  cure  may  be  attained  by  the  extirpation 
of  the  scar  and  by  the  exact  suture  of  the  abdominal 
wound,  which  should  be  performed  layer  by  layer,  as  is 
the  case  in  all  laparotomy  wounds  not  made  in  the  median 
line.  Two  layers  are  usually  sufficient  :  the  first  set  of 
sutures  are  of  catgut  and  are  passed  through  the  peritoneum 
and  the  entire  thickness  of  the  abdominal  muscles  and 
their  aponeuroses  ;  the  second  set  of  sutures  approximates 
the  edges  of  the  cutaneous  wound. 

The  treatment  by  means  of  a  truss  may  be  easily  carried 


262  HERNIA. 

out  in  the  majority  of  small  ventral  hernias,  and  particu- 
larly in  tlie  hernias  of  scars.  A  flat  pad  should  be 
employed  which  resembles  those  used  in  umbilical  hernias. 
Good  results  do  not  follow  the  use  of  trusses  for  large 
hernias  in  individuals  with  pendulous  abdomens,  and  in 
such  cases  some  form  of  abdominal  supporter  must  be 
employed  (page  228).  In  the  case  illustrated  in  figure 
106  an  abdominal  supporter  constructed  by  Mahrt  and 
Horning,  of  Gottingen,  was  most  satisfactory.  The  most 
important  part  of  the  support  was  an  elongated  quadrilat- 
eral frame  made  of  steel  strips,  which  was  so  applied  that 
the  long  sides  were  situated  immediately  to  either  side  of 
the  spinal  column  in  the  lower  dorsal  and  lumbar  region. 
The  frame  was  well  padded,  and  to  its  upper  extremity 
were  attached  two  padded  straps,  the  free  ends  of  which 
were  passed  around  the  shoulders  and  buttoned  on  the 
frame.  The  actual  suspensory  was  provided  with  four 
straps  upon  each  side  which  were  fastened  to  the  sides  of 
the  steel  frame.  The  entire  apparatus  Avas  so  constructed 
that  it  could  not  be  displaced  and  the  pressure  was  so 
evenly  distributed  over  a  large  portion  of  the  vertebral 
column  and  the  shoulders  that  it  caused  no  annoyance 
whatever. 

LUMBAR   HERNIA* 

A  lumbar  hernia  is  one  which  makes  its  appearance  in 
the  lumbar  region.  Since  Braun  (1879)  critically  studied 
and  analyzed  the  previously  known  cases  of  lumbar  hernia, 
29  in  number,  and  from  his  own  observation  pointed  out 
a  new  path  by  which  this  variety  could  develop,  a  series 
of  individual  observations  and  also  a  number  of  collections 


LUMBAR  HERNIA.  263 

(Grange  and  Besendonk)  have  been  published  upon  this 
subject  without  causing  any  actual  change  in  the  funda- 
mental views  established  by  Braun. 

In  the  dissection  of  the  posterior  lumbar  region  (Fig. 
108)  a  triangular  space  (Fig.  108,  d)  is  found  in  a  num- 
ber of  cases  which  is  known  as  the  triangle  of  Petit.  This 
triangle  is  bounded  by  the  crest  of  the  ilium,  the  latissimus 
dorsi  muscle,  and  tlie  external  oblique  muscle  ;  its  floor  is 
formed  by  the  internal  oblique  and  trans versalis  muscles 
and  by  tlie  transversalis  fascia.  This  triangle  of  Petit 
was  the  only  known  or  even  suspected  site  for  the  escape 
of  a  lumbar  hernia  ;  at  the  present  time,  however,  we  are 
forced  to  believe,  from  a  large  series  of  cases, — 51  in  the 
collections  of  Grange  and  Besendonk, — what  Braun  was 
able  to  state  in  his  time :  namely,  that  postmortem  exam- 
ination and  exact  dissection  have  never  yet  irrefutably 
proved  that  Petit' s  triangle  formed  the  hernial  orifice  in 
any  case.  A  similar  statement  may  be  made  in  refer- 
ence to  the  muscular  aperture  described  by  Grynfelt  and 
Lesshaft.  Just  above  Petit's  triangle  a  weak  place  is 
rather  frequently  found  Avhich  is  covered  only  by  the 
latissimus  dorsi ;  it  is  bounded  anteriorly  by  the  external 
oblique,  posteriorly  by  the  iliocostalis,  above  by  the  serra- 
tus  posticus  inferior  and  the  end  of  the  twelfth  rib,  and 
below  by  the  internal  oblique.  Lesshaft  named  this  space 
the  superior  lumbar  triangle,  and  believed  that  it  must  be 
considered  as  one  of  the  locations  at  which  lumbar  hernias 
made  their  appearance.  Xo  absolute  proof  has  as  yet  been 
furnished  that  a  hernia  has  ever  protruded  through  this 
space,  and  an  external  examination  in  the  living  subject 
(Bayer)  fails   to   demonstrate  such  complicated  anatomic 


264  •  HERNIA. 

details.  On  the  contrary,  Braun,  in  an  antopsy  upon 
an  individual  with  a  left-sided  lumbar  hernia,  was  able  to 
demonstrate  a  hernial  orifice  (Fig.  108,  c)  situated  in  the 
tense  fibers  of  the  latissimus  dorsi,  and  as  an  analogous 
opening  almost  as  large  in  size  was  found  upon  the  other 
side,  he  regarded  this  opening  as  a  congenital  predisposi- 
tion to  a  hernia.  Since  then  Hutchinson  and  Wyss  have 
both  had  an  opportunity  to  carefully  study  a  case  of  lum- 
bar hernia  at  autopsy  :  in  the  first  of  these  cases  the  hernia 
passed  through  the  aponeurosis  of  the  transversalisand  the 
latissimus  dorsi,  and  the  hernial  contents  consisted  of  de- 
scending colon  and  coils  of  small  intestine ;  in  the 
second  case  the  hernia  escaped  through  an  aperture  in 
the  external  oblique,  internal  oblique,  and  transversalis 
muscles,  and  the  sac  contained  the  ascending  colon. 

In  addition  to  the  previously  mentioned  possibility  of  a 
congenital  predisposition  and  of  injuries  of  the  lumbar 
region  producing  lacerations  of  the  muscles,  suppurations 
in  the  neighborhood  of  the  crest  of  the  ilium  exert  quite 
an  influence  upon  the  development  of  the  lumbar  hernias. 
In  the  majority  of  the  cases  which  have  been  carefully  ex- 
amined it  has  been  found  that  the  hernia  appeared  at  the  site 
of  a  preceding  suppurating  fistula,  which  was  usually  due 
to  a  gravitation  abscess,  but  which  occasionally  resulted 
(Wolff )  from  an  osteomyelitis  of  the  pelvis.  Why  the 
pus  should  pursue  this  course,  and  whether  it  follows  a  pre- 
existing path,  have  not  been  decided  at  the  present  time. 

If  the  possibility  of  the  occurrence  of  a  hernia  is  borne 
in  mind,  the  diagnosis  will  usually  be  made  without  diffi- 
culty, since  the  reducibility,  the  gurgling  murmur  upon 
reduction,  the  tympanitic   note  upon   percussion,  and  the 


INTERNAL  HERNIAS.  265 

enlargement  of  the  hernial  protrusion  upon  augmentation 
of  the  intra-abdominal  pressure  will  admit  of  no  other 
interpretation.  In  spite  of  all  this,  errors  have  occurred, 
since  the  hernia  has  been  repeatedly  mistaken  for  a  lipoma 
or  an  abscess,  and,  in  one  case  in  which  the  latter  diagnosis 
was  made,  the  subsequent  incision  wounded  the  intestine. 
Lumbar  hernias  have  frequently  been  treated  with  ban- 
dages, the  most  important  part  of  which  consisted  of  a 
flat  pad  placed  over  the  hernial  orifice,  and  it  has  been  re- 
peatedly observed  that  the  mouth  of  the  hernia  became 
markedly  smaller  under  the  influence  of  such  a  support. 
Although  a  number  of  strangulated  lumbar  hernias  have 
been  operated  upon,  but  two  non-strangulated  cases  have 
been  made  the  subject  of  surgical  intervention.  In  one 
case  Owen  performed  a  radical  operation  by  suturing  the 
hernial  orifice  with  catgut ;  the  second  case  Avas  operated 
upon  by  Kiister,  wdio  closed  the  orifice  w^ith  a  pedunculated 
skin-muscle-bone  flap. 


INTERNAL   HERNLVS* 

According  to  Bresike,  internal,  retroperitoneal,  or  intra- 
abdominal hernias  include  all  those  which  arise  within  the 
abdominal  cavity,  wdiether  they  develop  in  normal  perito- 
neal recesses,  or  in  abnormal  peritoneal  recesses  arising  in 
a  physiologic  manner.  It  will  be  seen  that  this  variety 
does  not  include  the  hernial  sacs  which  result  from  patho- 
logic processes,  such  as  the  formation  of  adhesions.  Since 
Treitz  (1857)  directed  attention  to  the  intra-abdominal 
hernias  and  to  the  locations  in  which  they  are  chiefly  found, 
our  knowledge  of  this  variety  of  hernia  has  been  greatly 


^66  HERNIA. 

extended  and  the  statistics  at  our  command  largely  in- 
creased. 

The  lesser  peritoneal  cavity  {bursa  omentalis)  may  be 
regarded  as  a  pre-existing  hernial  sac ;  other  places  in 
which  an  intra-abdominal  protrusion  of  the  peritoneum 
may  occur  are  the  peritoneal  recess  at  the  duodeno-jcjunal 
angle,  at  the  cecum,  at  the  sigmoid  mesocolon,  and  at  the 
anterior  abdominal  wall  in  the  vicinity  of  the  bladder. 
We  may  consequently  differentiate  five  varieties  of  internal 
hernia:  (1)  Hernia  of  the  foramen  of  Winslow ;  (2) 
hernia  of  the  duodeno-jejunal  recess ;  (3)  hernia  of  the 
retrocecal  and  ileocecal  recesses ;  (4)  hernia  of  the  inter- 
sigmoid  recess  ;    (5)  retrovesical  hernia. 

1.  The  hernia  of  the  foramen  of  Winslow  is  not  very 
frequent,  having  been  observed  only  eight  times,  accord- 
ing to  Maydl ;  the  hernias  were  strangulated  in  one-half 
of  these  cases.  The  rarity  of  the  hernia  is  explained  by 
the  narrowness  of  the  opening,  which,  on  account  of  the 
position  of  the  liver,  of  the  transverse  colon,  and  of  the 
transverse  mesocolon,  will  allow  of  the  passage  of  an  in- 
testinal coil  only  under  certain  circumstances.  According 
to  Merkel,  it  is  to  be  supposed  "that  either  an  abnormally 
long  mesentery  or  a  retardation  of  the  normal  process  of 
fixation  of  the  colon  must  exist  if  portions  of  the  intes- 
tine are  present  in  the  lesser  peritoneal  cavity." 

2.  At  the  transition  of  the  duodenum  into  the  jejunum 
a  number  of  peritoneal  diverticula  are  found,  chiefly  upon 
the  left  side,  none  of  which  are  constant.  It  is  of  practi- 
cal importance  to  remember  that  all  of  the  previously 
described  left-sided  hernias  of  this  region  have  been  found 
in  the  reeessus  duodeno-jejunaUs  sinister  or  venosus.     This 


INTERNAL  HERNIAS.  2G7 

peritoneal  pocket  was  named  by  Brosike,  and  may  be  rec- 
ognized by  the  fact  that  the  inferior  mesenteric  vein,  and 
occasionally  the  colica  sinistra  artery,  run  in  its  upper 
margin.  Figure  109,  A,  represents  a  duodeno-jcjunal 
recess.  In  these  cases  the  peritoneal  pocket  is  usually 
deeper  at  birth,  but  it  is  not  until  later  in  life  that  it  grad- 
ually becomes  distended  by  the  entrance  of  portions  of  the 
viscera.  According  to  Maydl,  the  literature  contains 
about  50  undoubted  cases  of  this  variety  of  hernia.  To 
these  must  be  added  some  rare  cases  in  which  the  hernia 
developed  to  the  right  of  the  plica  duodeno-jejunalis ;  the 
last  publication  upon  this  subject  is  one  by  A.  Neumann. 

These  hernias  vary  in  size  between  that  of  a  walnut  and 
that  of  a  man's  head.  When  they  attain  the  larger  dimen- 
sion, the  neck  of  the  hernial  sac  descends  so  low  that 
sometimes  it  is  situated  immediately  alongside  of  the  cecum 
and  can  only  be  recognized  as  the  recessus  duodeno-jejun- 
alis by  the  course  of  the  above-mentioned  vessels.  Figure 
110  represents  such  a  hernia  which  caused  no  symptoms 
whatever  during  life  and  which  was  accidentally  discov- 
ered at  the  Pathologic  Institute  at  Gottingen  by  an  autopsy 
upon  a  man  twenty-four  years  of  age  who  died  of  pul- 
monary tuberculosis. 

3.  According  to  Waldeyer,  there  are  three  peritoneal 
recesses  about  the  cecum.  The  parietal  peritoneum  as  it 
passes  to  the  anterior  surface  of  the  cecum  forms  a  fold 
which  is  called  the  plica  ccecalis ;  the  pocket  below  it  is 
the  fossa  ccecalisj  and  from  this  diverticulum  a  recessus 
rdro-cceealis  sometimes  extends  behind  tlie  cecum.  The 
second  pocket  is  situated  at  the  inner  side  of  the  cecum 
immediately  above  the  ileocecal  junction,  and  is  called  the 


268 


HERNIA. 


recessus  ileoccecalis  swperior  ;  it  is  very  flat  and  without  any- 
practical  significance,  since  it  has  never  yet  been  observed 
to  contain  a  hernia.      The  third  pocket  is  formed  by  the 


Fig.  109.— Recessus  duodeno-jejunalis  (A)  and  intersigmoideus  (B). 


INTERNAL  HERNIAS.  269 

plica  ileocaecalis  as  it  passes  from  the  mesenterioliiru  of 
the  appendix  to  the  anterior  surface  of  the  ileum.  It  is 
called  the  rccessm  ileoccecalis  Inferior  or  ileo-appendicidaris 
(Fig.  Ill),  and  has  been  observed  to  contain  hernias. 

There  have  been  only  a  few  examples  of  a  retrocecal 
hernia ;  the  last  description  of  a  carefully  examined  case 
was  published  by  A.  Aschoff.  Up  to  the  present  time 
there  have  been  recorded  but  three  cases  of  ileo-appendic- 
ular  hernia  (Snow,  Nasse,  and  Riese). 

4.  If  the  sigmoid  colon  is  raised  and  drawn  over  to- 
ward the  right  side,  the  entrance  to  a  small  fossa  is  some- 
times observed  at  the  root  of  the  sigmoid  mesocolon ;  this 
fossa  is  situated  behind  the  parietal  peritoneum,  and  is 
known  as  the  recessus  inter  si gmoideus  (Fig.  109,  B).  Her- 
nias into  this  pocket  are  extremely  rare,  only  two  cases, 
according  to  Jonnesco,  having  been  observed. 

5.  In  the  vicinity  of  the  bhadder,  in  rare  cases,  the 
plica  vesico-umbilicalis  lateralis  (Plate  2)  is  so  strongly 
developed  that  a  peritoneal  pocket  is  produced  which  may 
lead  to  the  formation  of  a  hernia.  Linhart,  Aschoff,  and 
Kaufmann  have  each  described  such  a  case  of  retrovesical 
hernia,  or,  as  it  is  called  by  Klebs,  hernia  retro-peritonealis 
anterior.  Another  and  very  remarkable  case  of  retrovesi- 
cal hernia  has  been  recorded  by  Saniter ;  in  this  instance 
the  retroperitoneal  hernial  sac  was  directed  toward  the 
pelvic  floor,  without  showing  any  tendency  to  pass  be- 
tween the  fibers  of  the  levator  ani  muscle  like  a  com- 
mencing perineal  hernia. 

Internal  hernias  cause  no  symptoms  until  they  become 
strangulated,  and  even  then  they  exhibit  such  scant  char- 
acteristics that,  with  the  exception  of  a  case  of  Stauden- 


Fig.  110. — Hernia  duodeno-jejunalis.  When  the  abdominal  cavity 
was  opened,  the  entire  small  intestine,  with  the  exception  of  a  small 
portion  of  the  jejunum  above  and  of  the  ileum  below,  was  found  in  a 
retroperitoneal  hernial  sac.  The  coils  of  small  intestine  could  easily 
be  drawn  out  of  the  hernial  sac,  as  no  adhesions  had  formed.  A 
white  cicatricial  ring  passed  from  the  edge  of  the  mouth  of  the  sac  to 
the  root  of  the  mesentery.  The  hernial  orifice  Avas  limited  above  by 
the  inferior  mesenteric  vein  and  below  by  the  colica  sinistra  artery, 
showing  that  the  hernia  was  situated  within  the  recessus  duodeno- 
jejunalis  (Aschoff). 

270 


INTERNAL  HERNIAS. 


271 


meyer,  it  has  never  yet  been  jx)ssiblc  to  make  the  diagnosis 
with  even  a  fair  degree  of  probability.  An  intestinal 
obstrnction  arising  from  other  causes  will  usually  produce 
exactly  the  same  symptoms. 


Fig.  111. — An  unusually  deep  recessus  ileocsecalis  inferior  or  ileo- 
appendicularis.  In  order  to  better  expose  this  recess,  its  upper  border 
has  been  raised  with  two  forceps  and  the  ileum  twisted  upon  its 
longitudinal  axis. 


The  treatment  is  that  of  every  intra-abdominal  intes- 
tinal obstruction.  As  soon  as  the  diagnosis  has  been 
certainly  made  the  removal  of  tlie  obstruction  and  con- 
sequent recovery  can  only  be  expected  from  a  laparotomy 


272  HERNIA. 

performed  at  the  earliest  possible  moment.  The  possibil- 
ity of  such  internal  hernias  should  be  borne  in  mind  dur- 
ing the  laparotomy,  and  if  other  causes  for  intestinal 
obstruction  are  wanting,  the  favorite  sites  of  their  occur- 
rence should  be  carefully  palpated.  The  hernial  orifice 
must  be  situated  at  the  point  to  which  the  distended  afferent 
and  the  collapsed  efferent  intestines  converge.  After  the 
hernia  has  been  found  and  the  strangulation  relieved,  it 
must  be  decided  whether  the  hernial  orifice  should  be  closed, 
and,  if  so,  the  method  of  suture.  Neumann  and  Nasse 
closed  the  orifices  in  their  cases  Avith  sutures,  but  Riese 
mentions  a  case  published  by  Schott  in  which  the  walls  of 
the  recessus  ileo-appendicularis  spontaneously  became  ad- 
herent and  formed  a  cyst  which  caused  a  fatal  ileus  by  press- 
ing upon  the  intestine.  Such  a  possibility  is  also  to  be  feared 
after  a  suture  of  the  hernial  orifice.  Since  the  extirpation 
of  a  retroperitoneal  sac  is  not  practicable,  particularly  in 
large  hernias,  I  would  recommend,  for  hernias  of  the  cecal 
region  and  of  the  iutersigmoid  fossa,  that  the  cavity  should 
be  packed  for  a  certain  length  of  time  so  as  to  excite  the 
formation  of  granulation  tissue  and  an  adhesion  of  the 
walls.  In  the  other  varieties  of  internal  hernia  it  would 
probably  be  better  to  entirely  disregard  the  closure  of  the 
hernial  orifice. 

The  results  obtained  in  the  treatment  of  strangulated 
internal  hernias  have  been  greatly  improved  in  the  last 
ten  years.  While  Jonnesco  (1890)  stated  that  the  three 
cases  previously  operated  upon  terminated  fatally,  as  did 
all  of  those  which  were  not  operated  upon,  Riese  (1900) 
reported  nine  cases  operated  upon  in  the  antiseptic  period 
with  four  recoveries. 


INDEX. 


Accidents  of  hernia,  80 
Acquired  external  inguinal  hernia, 

146 
Anus,  artificial,   in  strangulated 

hernia,  126 
Apparent  hernia,  47 
Artificial    anus    in    strangulated 

hernia,  126 

Bassini's  operation  for  femoral 

hernia,  204 
Bassini's  operation   for  inguinal 

hernia,  173 

Children,  umbilical  hernia  of, 
215 

radical  operation  for,  221 

treatment  of,  217 
Complete  inguinal  hernia,  147 
Congenital  inguinal  hernia,  143 
umbilical  hernia,  209 

treatment  of,  213 
Contents  of  the  hernia,  35 
Coverings  of  a  hernia,  45 
Cross-body  truss,  67 

Diaphragmatic  hernia,  244 

treatment  of,  250 
Duodeno-jejunal  recess,  hernia  of, 
266 

18  273 


Earning    power    of   individual 

with  a  hernia,  135 
Elastic  strangulated  hernia,  88 
Epigastric  hernia,  251 
External  acquired  inguinal  hernia, 
146 

oblique  inguinal  hernia,  143 

Fat  hernia,  47 

Fecal  stasis  in  hernia,  80 
strangulated  hernia,  91 

Femoral  hernia,  185 

Bassini's  operation  for,  204 
diagnosis  of,  190 
Kocher's  operation  for,  205 
osteoplastic  operation  for,  206 
purse-string  operation  in,  204 
radical  operation  for,  202 
Salzer's  operation  for,  206 
Schwartz's  operation  for,  206 
strangulation  of,  199 
treatment  of,  201 
Trendelenburg-Kraske  oper- 
ation for,  206 
truss  in,  201 

Witzel's  operation  for,  207 
region,  anatomy  of,  186 
truss,  double,  202 

method  of  application,  203 
single,  202 


274 


INDEX. 


Foramen  of  Winslow,  hernia  of, 

266 
French  truss,  66 
Frequency  of  hernia,  18 

Hernia,  accidents  of,  80 

acquired  external  inguinal,  146 
apparent,  47 
complete  inguinal,  147 
congenital  inguinal,  143 

umbilical,  209 
treatment  of,  213 
contents  of,  35 
coverings  of,  45 
diagnosis  of,  58 
diaphragmatic,  244 

treatment  of,  250 
earning    power    of    individual 

with,  135 
elastic  strangulated,  88 
epigastric,  251 
expert  opinions  in  reference  to, 

135 
fat,  47 
fecal  stasis  in,  80 

strangulated,  91 
femoral,  185 

Bassini's  operation  for,  204 

diagnosis  of,  190 

Kocher's  operation  for,  205 

radical  operation  for,  202 

Salzer's  operation  for,  206 

Schwartz's  operation  for,  206 

strangulation  of,  199 

treatment  of,  201 

Trendelenburg-Kraske   oper- 
ation for,  206 

truss  in,  201 

Witzel's  operation  for,  207 
frequency  of,  18 


Hernia,  incomplete  inguinal,  147 

inflammation  of,  82 

inguinal,  139 

and  hydrocele    testis,    diag- 
nosis, differential,  161 
Bassini's  operation  for,  173 
diagnosis  of,  150 
external  o])lique,  143 
Kocher's  operation  for,  175 
Macewen's  operation  for,  180 
radical  operation  for,  172 
treatment  of,  169 
truss  in,  169 

inguino-perineal,  243 

internal,  265 

treatment  of,  271 

interparietal  inguinal,  166 

interstitial  inguinal,  167 

large  intestine  as  contents  of,  39 

lateral  ventral,  260 
treatment  of,  261 

lumbar,  262 

treatment  of,  265 

mouth  of,  19 

obturator,  230 
diagnosis  of,  232 
treatment  of,  234 

of  duodeno-jejunal  recess,  266 

of  foramen  of  Winslow,  266 

of  intersigmoid  recess,  269 

of  lineaalba,  250 

treatment  of,  258 

of  retrocecal  and   ileocecal  re- 
cesses, 267 

omentum  as  contents  of,  39 

origin  of,  50 

palliative  treatment  of,  64 

perineal,  238 
diagnosis  of,  242 

preperitoneal  inguinal,  167 


INDEX. 


275 


Hernia,  radical  operation  for,  08 
mortality  of,  73 
recurrences  after,  77 
retrograde  strangulated,  106 
retrovesical,  269 
sac  of,  31 
sciatic,  235 
small  intestine  as  contents  of, 

37 
strangulated,  87 

apparent  reduction  in,  114 
artificial  anus  in,  126 
course  of,  99 
diagnosis  of,  106 
herniotomy  for,  115 
mortalit}'^  of,  116 
resection  of  intestine  in,  126 
symptoms  of,  99 
taxis  in,  107 
treatment  of,  107 
superficial  inguinal,  168 
treatment  of,  63 
umbilical,  208 
of  adults,  222 

diagnosis,  differential,  227 
treatment  of,  227 
of  children,  215 

radical  operation  for,  221 
treatment  of,  217 
varieties  of,  139 
ventral,  250 
Herniotomy  for  strangulated  her- 
nia, 115 
mortality  of,  116 
Hydrocele  testis  and  inguinal  her- 
nia, diagnosis,  differential,  161 

Ileocecal    and    retrocecal    re- 
cesses, hernia  of,  267 
Incomplete  inguinal  hernia,  147 


Inflammation  of  a  hernia,  82 
Inguinal  hernia,  acquired  exter- 
nal, 146 

and  hydrocele  testis,  diagno- 
sis, differential,  161 

Bassini's  operation  for,  173 

complete,  147 

congenital,  143 

diagnosis  of,  150 

external  ol)lique,  143 

incomj)lete,  147 

internal,  148 

interparietal,  166 

interstitial,  167 

Kocher's  operation  for,  175 

Macewen's  operation  for,  180 

preperitoneal,  167 

radical  operation  for,  172 

superficial,  168 

treatment  of,  169 

truss  in,  169 
region,  anatomy  of,  139 
Inguino-perineal  hernia,  243 
Internal  hernia,  265 

treatment  of,  271 
inguinal  hernia,  148 
Interparietal  inguinal  hernia,  166 
Intersigmoid  recess,  hernia  of,  269 
Interstitial  inguinal  hernia,  166 
Intestine,    large,   as  contents  of 

hernia,  39 
small,  as  contents  of  hernia,  37 

Kochee's   operation  for  femoral 
hernia,  205 
for  inguinal  hernia,  175 

Lateral  ventral  hernia,  260 
treatment  of,  261 


276 


INDEX. 


Linea  alba,  hernia  of,  250 

treatment  of,  258 
Lipomas,  subperitoneal,  47 
Lumbar  hernia,  262 
treatment  of,  265 

Macewen's    operation    for    in- 
guinal hernia,  180 
Mortality  of  herniotomy  for  stran- 
gulated hernia,  116 
of  radical  operation  for  hernia, 
73 
Mouth  of  the  hernia,  19 

Obturatok  hernia,  230 
diagnosis  of,  232 
treatment  of,  234 
region,  anatomy  of,  230 
Omentum  as  the  contents  of  her- 
nia, 39 
strangulation  of,  103 
Operation,  Bassini's,   for  femoral 
hernia,  204 
for  inguinal  hernia,  173 
Kocher's,    for  femoral   hernia, 
205 
for  inguinal  hernia,  175 
Macewen's,  for  inguinal  hernia, 

180 
purse-string,  for  femoral  hernia, 

204 
radical,  for  femoral  hernia,  202 
for  hernia,  68 
mortality  of,  73 
recurrences  after,  77 
for  inguinal  hernia,  172 
for  umbilical  hernia  of  chil- 
dren, 221 
Salzer's,  for  femoral  hernia,  206 


Operation,  Schwartz's,  for  femoral 
hernia,  206 
Trendelenburg-Kraske,  for  fem- 
oral hernia,  206 
Witzel's,    for   femoral    hernia, 
207 
Opinions,  expert,  in  reference  to 
hernias,  135 

Perineal  hernia,  238 

diagnosis  of,  242 
Pomeroy  truss,  171 
Properitoneal    inguinal     hernia, 

167 
Purse-string  operation  for  femoral 

hernia,  204 

Eadical  operation    for  femoral 
hernia,  202 
for  hernia,  68 
mortality  of,  73 
recurrences  after,  77 
for  inguinal  hernia,  172 
for  umbilical  hernia  of  chil- 
dren, 221 
Retrocecal  and  ileocecal  recesses, 

hernia  of,  267 
Retrograde   strangulated  hernia, 

106 
Retrovesical  hernia,  269 

Sac  of  the  hernia,  31 

Salzer's     operation    for    femoral 

hernia,  206 
Schwartz's  operation  for  femoral 

hernia,  206 
Sciatic  hernia,  235 
Strangulated  hernia,  87 

apparent  reduction  in,  114 
artificial  anus  in,  126 


INDEX. 


277 


Strangulated    hernia,   course  of, 
99 
diagnosis  of,  106 
herniotomy  for,  115 
mortality  of,  116 
resection  of  intestine  in,  126 
symptoms  of,  99 
treatment  of,  107 
Strangulation,  elastic,  88 
fecal,  91 

of  femoral  hernia,  199 
of  omentum,  103 
Subperitoneal  lipomas,  47 
Superficial  inguinal  hernia,  168 

Taxis    in    strangulated    hernia, 

107 
Testis,    hydrocele,    and   inguinal 

hernia,    diagnosis,  differential, 

161 
Trendelenburg-Kraske   operation 

for  femoral  hernia,  206 
Truss,  cross-body,  67 


Truss,  double  femoral,  202 

femoral,  method  of  application, 

203 
French,  66 
single  femoral,  202 

Umbilical  hernia,  208 
congenital,  209 

treatment  of,  213 
of  adults,  222 

diagnosis,  differential,  227 

treatment  of,  227 
of  children,  215 

radical  operation  for,  221 

treatment  of,  217 

Varieties  of  hernia,  139 
Ventral  hernia,  250 

WiNSLOW,  foramen  of,  hernia  of, 

266 
"SVitzel's    operation    for    femoral 

hernia,  207 


Catalogue    the    Medical     Publications 


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AN  AMERICAN  TEXT=BOOK  OF  APPLIED  THERAPEUTICS. 

Edited  by  jAMES  C.  Wilson,  M.  D.,  Professor  of  Practice  of  Medicine  and 
of  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia.  Handsome 
imperial  octavo  volume  of  1326  pages.  Illustrated.  Cloth,  ^7.00  net; 
Sheep  or  Half  Morocco,  $8.00  net. 

AN  AMERICAN  TEXT=BOOK  OF  THE   DISEASES  OF  CHIL= 
DREN.    Second  Edition,  Revised. 

Edited  by  Louis  Starr,  M.  D.,  Consulting  Pediatrist  to  the  Maternity  Hos- 
pital, etc.  ;  assisted  by  Thompson  S.  Westcott,  M.D.,  Attending  Physi- 
cian to  the  Dispensary  for  Diseases  of  Children,  Hospital  of  the  University 
of  Pennsylvania.  Handsome  imperial  octavo  volume  of  1244  pages,  pro- 
fusely illustrated.     Cloth,   ^7.00  net  ;  Sheep  or  Half  Morocco,  ^8.00  net. 

AN  AMERICAN  TEXT=BOOK  OF   DISEASES  OF  THE   EYE, 
EAR,  NOSE,  AND  THROAT. 

Edited  by  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology, 
Jefferson  Medical  College,  Philadelphia ;  and  B.  Alexander  Randall. 
M.  D.,  Clinical  Professor  of  Diseases  of  the  Ear,  University  of  Pennsylvania. 
Imperial  octavo,  1251  pages  ;  766  illustrations,  59  of  them  in  colors.  Cloth, 
^7.00  net;  Sheep  or  Half  Morocco,  ;^8.oo  net. 


MEDICAL   PUBLICATIONS 


AN    AMERICAN    TEXT=BOOK    OF    QENITO=URINARY     AND 

SKIN  DISEASES. 

Edited  by  L.  BOLTON  Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery, 
University  and  Bellevue  Hospital  Medical  College,  New  York  ;  and  W.  A. 
Hardaway,  M.  D.,  Professor  of  Diseases  of  the  Skin  and  Syphilis,  Wash- 
ington University,  St.  Louis.  Imperial  octavo  volume  of  1229  pages,  with 
300  engravings  and  20  full-page  colored  plates.  Cloth, ^7.00  net;  Sheep  or 
Half  Morocco,  ^8.00  net. 

AN    AMERICAN  TEXT=BOOK  OF   GYNECOLOGY,  MEDICAL 
AND  SURGICAL.    Second  Edition,  Revised. 

Edited  by  J.  M.  Baldy,  M.  D.,  Professor  of  Gynecology,  Philadelphia 
Polyclinic,  etc.  Handsome  imperial  octavo  volume  of  718  pages  ;  341  illus- 
trations in  the  text,  and  38  colored  and  half-tone  plates.  Cloth,  ^6.00  net ; 
Sheep  or  Half  Morocco,  ;^7.oo  net. 

AN    AMERICAN    TEXT=BOOK  OF    LEGAL    MEDICINE    AND 
TOXICOLOGY. 

Edited  by  FREDERICK  PETERSON,  M.  D.,  Chief  of  Clinic,  Nervous  Depart- 
ment, College  of  Physicians  and  Surgeons,  New  York  ;  and  WALTER  S. 
Haines,  M.  D.,  Professor  of  Chemistry,  Pharmacy,  and  Toxicology,  Rush 
Medical  College,  Chicago.     In  Preparation. 

AN  AMERICAN  TEXT=BOOK  OF  OBSTETRICS. 

Edited  by  RICHARD  C.  NORRIS,  M.  D.  ;  Art  Editor,  ROBERT  L.  DICKINSON, 
M.  D.  Handsome  imperial  octavo  volume  ©f  1014  pages  ;  nearly  900  beau- 
tiful colored  and  half-tone  illustrations.  Cloth,  ^7.00  net ;  Sheep  or  Half 
Morocco,  ^8.00  net. 

AN  AMERICAN  TEXT-BOOK  OF  PATHOLOGY. 

Edited  by  LUDVIG  Hektoen,  M.  D.,  Professor  of  Pathology  in  Rush 
Medical  College,  Chicago;  and  DAVID  RiESMAN,  M.  D.,  Professor  of 
Clinical  Medicine,  Philadelphia  Polyclinic.  Imperial  octavo  of  1245  pages, 
443  illustrations,  66  in  colors.  Cloth,  ^7.50  net;  Sheep  or  Half  Morocco, 
^8.50  net.     By  Subscription. 

AN  AMERICAN  TEXT=BOOK  OF  PHYSIOLOGY.    Second  Edi- 
tion, Revised,  in  Two  Volumes. 

Edited  by  WILLIAM  H.  HoWELL,  Ph.  D.,  M.  D.,  Professor  of  Physiology, 
Johns  Hopkins  University,  Baltimore,  Md.  Two  royal  octavo  volumes  of 
about  600  pages  each.  Fully  illustrated.  Per  volume:  Cloth,  ;^3.oo  net; 
Sheep  or  Half  Morocco,  ^3.75  net. 

k^  AMERICAN  TEXT=BOOK  OF  SURGERY.    Third  Edition. 

Edited  by  WILLIAM  W.  KEEN.  M.  D.,  LL.D.,  F.  R.  C.  S.  (Hon.);  and 
J.  William  White,  M.  D.,  Ph.  D.  Handsome  octavo  volume  of  1230 
pages  ;  496  wood-cuts  and  37  colored  and  half-tone  plates.  Thoroughly 
revised  and  enlarged,  with  a  section  on  "  The  Use  of  the  Rontgen  Rays  in 
Surgery."     Cloth,  $7.00  net;  Sheep  or  Half  Morocco,  ^8.00  net. 

AN  AMERICAN  TEXT=BOOK  OF  THEORY  AND  PRACTICE  OF  MEDICINE. 

Edited  by  the  late  William  Pepper,  M.  D..  LL.D..  Professor  of  the  Theory  and 
Practice  of  Medicine  and  of  Clinical  Medicine,  University  of  Pennsylvania.  Two 
handsome  imperial  octavos  of  about  1000  pages  each.  Illustrated.  Per  volume  :  Cloth, 
$5.00  net ;  Sheep  or  Half  Morocco,  ;^6.oo  net. 


OF  VV.  B.  SAUNDERS  6-  CO. 


GET   THE   BEST  THE   NEW   STANDARD 

THE    AMERICAN    ILLUSTRATED    MEDICAL    DICTIONARY. 
Second  Edition,  Revised. 

For  Practitioners  and  Students.  A  Complete  Dictionary  of  the  Terms  used 
in  Medicine,  Surgery,  Dentistry,  Pharmacy,  Chemistry,  and  the  ivindred 
branches,  including  much  collateral  information  of  an  encyclopedic  character, 
together  with  new  and  elaborate  tables  of  Arteries,  Muscles,  Nerves,  Veins, 
etc.  ;  of  Bacilli,  Bacteria,  Micrococci,  Streptococci ;  Eponymic  Tables  of 
Diseases,  Operations,  Signs  and  Symptoms,  Stains,  Tests,  Methods  of  Treat- 
ment, etc.,  etc.  By  W.  A.  Newman  Dorland,  A.  M.,  M.  D.,  Editor 
of  the  "  American  Pocket  Medical  Dictionary."  Handsome  large  octavo, 
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Gives  a  Maximum  Amount  of  Matter  in  a  Minimum  Space  and  at  the  Lowest 

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This  Revised  Edition  contains  all  the  Latest  Terms. 

"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  within 
relatively  smal'  space.  I  find  nothing  to  criticise,  very  much  to  commend,  and  was  in- 
terested in  fin  iing  some  of  the  new  words  which  are  not  in  other  recent  dictionaries." — 
RoswELL  Park,  Professor  of  Principles  and  Practice  of  Surgery  and  Clinical  Surgery, 
University  of  Buffalo. 

"  I  congratulate  you  upon  giving  to  the  profession  a  dictionary  so  compact  in  its  structure, 
and  so  replete  with  information  required  by  the  busy  practitioner  and  student.  It  is  a 
necessity  as  well  as  an  informed  companion  to  every  doctor.  It  should  be  upon  the  desk 
of  every  practitioner  and  student  of  medicine." — John  B.  Murphy,  Professor  of  Surgery 
and  Clinical  Surgery,  Northwestern  University  Medical  School,  Chicago. 

THE  AMERICAN    POCKET    MEDICAL    DICTIONARY.    Third 

Edition,  Revised. 

Edited  by  W.  A.  Newman  Borland.,  M.  D.,  Assistant  Obstetrician  to  the 
Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  American  Acad- 
emy of  Medicine.  Containing  the  pronunciation  and  definition  of  the  prin- 
cipal words  used  in  medicine  and  kindred  sciences,  with  64  extensive  tables. 
Handsomely  bound  in  flexible  leather,  with  gold  edges.  Price  ^i-oo  riet ; 
with  thumb  index,  $1.25  net. 

THE  AMERICAN  YEAR=BOOK  OF  MEDICINE  AND  SURGERY. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs,  and 
text-books  of  the  leading  American  and  Foreign  authors  and  investigators. 
Arranged  with  editorial  comments,  by  eminent  American  specialists,  under 
the  editorial  charge  of  George  M.  Gould,  M.  D.  Year-Book  of  1902 
in  two  volumes — Vol.  I.  including  General  Medicine  ;  Vol.  H.,  General  Sur- 
gery. Per  volume  :  Cloth,  $3.00  net ;  Half  Morocco,  $3.75  net.  Sold  by  Sub- 
scription. 

ABBOTT  ON   TRANSMISSIBLE  DISEASES.    Second  Edition, 
Revised. 

The  Hygiene  of  Transmissible  Diseases:  their  Causation,  Modesof  Dissem- 
ination'i  and  Methods  of  Prevention.  By  A.  C.  ABBOTT,  M.  D.,  Professor 
of  Hygiene  and  Bacteriology,  University  of  Pennsylvania.  Octavo,  351 
pages,  with  numerous  illustrations.     Cloth,  $2.50  net. 


MEDICAL   PUBLICATIONS 


ANDERS'  PRACTICE  OF  MEDICINE.     Fifth  Revised  Edition. 

A  Text-Book  of  the  Practice  of  Medicine.  By  jAMES  M.  ANDERS,  M.  D., 
Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical  Med- 
icine, Medico-Chirurgical  College,  Philadelphia.  Handsome  octavo  volume 
of  1297  pages,  fully  illustrated.  Cloth,  $5.50  net;  Sheep  or  Half  Morocco, 
$(3.^0  net. 

BASTIN'S  BOTANY. 

Laboratory  Exercises  in  Botany.  By  Edson  S.  Bastin,  M.  A.,  late  Pro- 
fessor of  Materia  Medica  and  Botany,  Philadelphia  College  of  Pharmacy. 
Octavo,  536  pages,  with  87  plates.     Cloth,  ^2.00  net. 

BECK  ON  FRACTURES. 

Fractures.  By  CARL  BECK,  M.  D.,  Surgeon  to  St.  Mark's  Hospital  and 
the  New^  York  German  Poliklinik,  etc.  With  an  appendix  on  the  Practical 
Use  of  the  Rontgen  Rays.     335  pages,  170  illustrations.     Cloth,  ^3.50  net. 

BECK'S  SURGICAL   ASEPSIS. 

A  Manual  of  Surgical  Asepsis.  By  CARL  BECK,  M.  D.,  Surgeon  to  St. 
Mark's  Hospital  and  the  New  York  German  Poliklinik,  etc.  306  pages;  65 
text-illustrations  and  12  full-page  plates.     Cloth,  $1.25  net. 

BERGEY'S   PRINCIPLES  OF  HYGIENE, 

The  Principles  of  Hygiene :  A  Practical  Manual  for  Students,  Physicians, 
and  Health  Officers.  By  D.  H.  Bergey,  A.M.,  M.  D.,  First  Assistant, 
Laboratory  of  Hygiene,  University  of  Pennsylvania.  Handsome  octavo 
volume  of  495  pages,  illustrated.     Cloth,  ^3.00  net. 

BOISLINIERE'S    OBSTETRIC   ACCIDENTS,    EMERGENCIES, 

AND  OPERATIONS. 

Obstetric  Accidents,  Emergencies,  and  Operations.  By  L.  Ch.  BoisliN- 
ifeRE,  M.  D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis  Medical  Col- 
lege.    381  pages,  handsomely  illustrated.     Cloth,  #2.00  net. 

BOHM,   DAVIDOFF,   AND   HUBER'S  HISTOLOGY. 

A  Text-Book  of  Human  Histology.  Including  Microscopic  Technic.  By 
Dr.  a.  a.  BoHM  and  Dr.  M.  von  Davidoff,  of  Munich,  and  G.  CARL 
Huber,  M.  D.,  Junior  Professor  of  Anatomy  and  Director  of  Histological 
Laboratory,  University  of  Michigan.  Handsome  octavo  of  501  pages,  with 
351  beautiful  original  illustrations.     Cloth,  ^3.50  net. 

BROWER'S  MANUAL  OF  INSANITY. 

A  Practical  Manual  of  Insanity.  For  the  Student  and  General  Practitioner. 
By  Daniel  R.  Brower,  A.  M.,  M.  D.,  LL.  D.,  Professor  of  Nervous  and 
Mental  Diseases  in  Rush  Medical  College,  in  Affiliation  with  the  University 
of  Chicago,  and  in  the  Post-Graduate  Medical  School,  Chicago  ;  and  HENRY 
M.  Bannister,  A.  M.,  M.  D.,  formerly  Senior  Assistant  Physician,  Illinois 
Eastern  Hospital  for  the  Insane.  Handsome  octavo  of  426  pages,  with  13 
full-page  inserts.     Cloth,  $3.00  net. 


OF   W.  B.  SAUNDERS  <5h    CO. 


BUTLER'S      MATERIA      MEDICA,     THERAPEUTICS,     AND 
PHARMACOLOGY.    Third  Edition,  Revised. 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pluirniacology.  By 
George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  of  Materia  Medica  and  of 
Clinical  Medicine,  College  of  Physicians  and  Surgeons.  Chicago.  Octavo, 
874  pages,  illustrated.    Cloth,  5400  net ;  Sheep  or  Half  Morocco,  ;^5.oo  net. 

CHAPIN  ON  INSANITY. 

A  Compendium  of  Insanity.  By  JOHN  B.  Chapin,  M.  D.,  LL.D.,  Phy- 
sician-in-Chief,  Pennsylvania  Hospital  for  the  Insane;  Honorary  Member 
of  the  Medico-Psychological  Society  of  Great  Britain,  of  the  Society  of 
Mental  Medicine  of  Belgium,  etc.  i2mo,  234  pages,  illustrated.  Cloth, 
^1.25  net. 

CHAPMAN'S  MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 
Second  Edition,  Revised. 

Medical  jurisprudence  and  Toxicology.  By  HENRY  C.  CHAPMAN,  M.  D., 
Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence,  Jefferson 
Medical  College  of  Philadelphia.  254  pages,  with  55  illustrations  and  3 
full-page  plates  in  colors.     Cloth,  ^1.50  net. 

CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DIS- 
EASES.    Third  Edition,  Revised  and  Enlarged. 

Nervous  and  Mental  Diseases.  By  Archibald  Chlrch,  M.  D.,  Pro- 
fessor of  Nervous  and  Mental  Diseases,  and  Head  of  the  Neurological 
Department,  Northwestern  University  Medical  School,  Chicago ;  and 
Frederick  Peterson,  M.  D.,  Chief  of  Chnic,  Nervous  Department,  Col- 
lege of  Phvsicians  and  Surgeons,  New  York.  Handsome  octavo  volume  of 
87s  pages,' profusely  illustrated.  Cloth,  $5.00  net ;  Sheep  or  Half  Morocco, 
^6.00  net. 

CLARKSON'S  HISTOLOGY. 

A  Text-Book  of  Histology,  Descriptive  and  Practical.  By  ARTHUR  Clark- 
SON,  M.  B.,  C.  M.  Edin.,  formerly  Demonstrator  of  Physiology  in  the  Owen's 
College,  Manchester  ;  late  Demonstrator  of  Physiolog}^  in  Yorkshire  College, 
Leeds.  Large  octavo,  554  pages  ;  22  engravings  and  174  beautifully  colored 
original  illustrations.     Cloth,  S4.00  net. 

CORWIN'S  PHYSICAL  DIAGNOSIS.    Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  ARTHUR  M.  CORWIN, 
A.  M.,  M.  D.,  Late  Instructor  in  Physical  Diagnosis  in  Rush  Medical  Col- 
lege, Chicago.     219  pages,  illustrated.     Cloth,  ^1.25  net. 

CROTHERS'  MORPHINISM  AND  NARCOMANIA. 

Morphinism  and  Narcomania  from  Opium,  Cocain,  Ether,  Chloral.  Chloro- 
form, and  other  Narcotic  Drugs  ;  also  the  Etiology,  Treatment,  and  Medi- 
colegal Relations.  Bv  T.  D.  Crothers,  M.  D.,  Superintendent  of  Walnut 
Lodge  Hospital,  Hartford,  Conn.  ;  Professor  of  Mental  and  Nervous  Dis- 
eases, New  York  School  of  Clinical  Medicine,  etc.  Handsome  i2mo  of  351 
pages.     Cloth,  $2.00  net. 


6  MEDICAL   PUBLICATIONS 


DACOSTA'S  SURGERY.    Third  Edition,  Revised. 

Modern  Surgerv,  General  and  Operative.  By  John  Chalmers  DaCosta, 
M.  D.,  Professor  of  Principles  of  Surgery  and  Clinical  Surgery,  Jefferson 
Medical  College,  Philadelphia ;  Surgeon  to  the  Philadelphia  Hospital,  etc. 
Handsome  octavo  volume  of  1117  pages,  profusely  illustrated.  Cloth,  ;^5.oo 
net;  Sheep  or  Half  Morocco,  ^6.00  net. 

Enlarged  by  over  200  Pages,  with  more  than  100  New  Illus- 
trations. 

DAVIS'S  OBSTETRIC  NURSING. 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  IvL,  M.  D., 
Professor  of  Obstetrics  in  Jefferson  Medical  College  and  the  Philadelphia 
PolycUnic ;  Obstetrician  and  Gynecologist  to  the  Philadelphia  Hospital. 
i2mo  volume  of  400  pages,  fully  illustrated.     Crushed  buckram,  ^1.75  net. 

DE  SCHWEINITZ  ON  DISEASES  OF  THE  EYE.    Third  Edi- 
tion, Revised. 

Diseases  of  the  Eye.  A  Handbook  of  Ophthalmic  Practice.  By  G.  E. 
DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical 
College,  Philadelphia,  etc.  Handsome  royal  octavo  volume  of  696  pages ; 
256  fine  illustrations  and  2  chromo-lithographic  plates.  Cloth,  ^4.00  net ; 
Sheep  or  Half  Morocco,  ^5.00  net. 

DORLAND'S  DICTIONARIES. 

[See  American  Illustrated  Medical  Dictionary  and  American 
Pocket  Medical  Dictionary  on  page  3.] 

DORLAND'S    OBSTETRICS.      Second    Edition,    Revised    and 
Greatly  Enlarged. 

Modern  Obstetrics.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania;  Associate  in  Gyne- 
cology, Philadelphia  Polyclinic.  Octavo  volume  of  797  pages,  with  201 
illustrations.     Cloth,  ^4.00  net. 

EICHHORST'S  PRACTICE  OF  MEDICINE. 

A  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  Herman  Eichhorst, 
Professor  of  Special  Pathologv  and  Therapeutics  and  Director  of  the  Medi- 
cal Clinic,  University  of  Zurich.  Translated  and  edited  by  AUGUSTUS  A. 
ESHNER,  M.  D,,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic. 
Two  royal  octavo  volumes,  600  pages  each,  150  illustrations.  Per  set : 
Cloth,  ^6.00  net;  Sheep  or  Half  Morocco,  $7.50  net. 

FRIEDRICH  AND  CURTIS  ON  THE  NOSE,  THROAT,  AND 
EAR. 

Rhinology,  Laryngology,  and  Otology,  and  their  Significance  in  General 
Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited  by  H.  Holbrook 
Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York  Nose  and  Throat  Hos- 
pital.    Octavo,  348  pages.     Cloth,  ^2.50  net. 

FROTHINGHAM'S  GUIDE  FOR  THE  BACTERIOLOGIST. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Frothingham, 
M.  D.  v..  Assistant  in  Bacteriology  and  Veterinary  Science,  Sheffield  Scien- 
tific School,  Yale  University.     Illustrated.     Cloth,  75  cts.  net. 


OF  W.  B.   SAUNDERS  ^  CO. 


QALBRAITH  ON  THE  FOUR  EPOCHS  OF  WOMAN'S  LIFE. 

The  Four  Epochs  of  Woman's  Life.  A  Study  in  Hygiene.  By  Anna  M. 
Galbraith,  M.  D.,  Author  of  "  Hygiene  and  Physical  Culture  for  Women"; 
Fellow  of  the  New  York  Academy  of  Medicine,  etc.  With  an  Introductory 
Note  by  JOHX  H.  MusSER,  M.  D.^  Professor  of  Clinical  Medicine,  Uniyersity 
of  Pennsylvania.     i2mo  volume  of  200  pages.     Cloth,  $1.25  net. 

QARRIQUES'  DISEASES  OF  WOMEN.     Third  Ed.,  Revised. 

Diseases  of  Women.  By  Henry  J.  Garkigles,  A.  M.,  M.  D.,  Gynecolo- 
gist to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New  York  City. 
Octavo,  756  pages,  with  367  engravings  and  colored  plates.  Cloth,  $4.50 
net;  Sheep  or  Half  Morocco,  $5.50  net. 

QORHAM'S  BACTERIOLOGY. 

A  Laboratory  Course  in  Bacteriology.  By  F.  P.  GORHAM,  M,  A.,  Assistant 
Professor  in  Biolog^^  Brown  University.  i2mo  volume  of  192  pages,  97 
illustrations.     Cloth,  $1.25  net. 

GOULD  AND  PYLE'S  CURIOSITIES  OF  MEDICINE. 

Anomalies  and  Curiosities  of  Medicine.  By  George  ^L  GoULD,  M.  D., 
and  Walter  L.  Pyle,  J^L  D.  An  encyclopedic  collection  of  rare  and  ex- 
traordinary cases  and  of  the  most  striking  instances  of  abnormality  in  all 
branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive  research  of 
medical  literature  from  its  origin  to  the  present  day,  abstracted,  classified, 
annotated,  and  indexed.  Handsome  octavo  volume  of  968  pages ;  295  en- 
gravings and  12  full-page  plates.  Popular  Edition.  Cloth,  S3 .00  net ;  Sheep 
or  Half  Morocco,  S4.00  net. 

GRADLE  ON  THE  NOSE,  THROAT,  AND  EAR. 

Diseases  of  the  Nose,  Throat,  and  Ear.  By  Henry  Gradle,  ^L  D.,  Pro- 
fessor of  Ophthalmology  and  Otology,  Northwestern  University  Medical 
School,  Chicago.     Octavo,  500  pages,   illustrated.     Cloth,  $0.00  net. 

QRAFSTROM'S  MECHANO-THERAPY. 

A  Text-Book  of  Mechano-Therapy  (Massage  and  Medical  Gymnastics). 
By  Axel  V.  Grafstrom,  B.  Sc,  ^L  D.,  late  House  Physician,  City  Hos- 
pital, Blackwell's  Island,  N.  Y.    i2mo,  139  pages,  illustrated'.   Cloth,  $1.00  net. 

GRIFFITH  ON  THE  BABY.    Second  Edition,  Revised. 

The  Care  of  the  Babv.  Bv  J.  P.  Crozer  Griffith,  ^L  D.,  Clinical  Pro- 
fessor of  Diseases  of  Children,  University  of  Pennsylvania  ;  Physician  to  the 
Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages,  67  illustrations 
and  5  plates.     Cloth,  $1.50  net. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  GRIFFITH,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania.  25 
charts  in  each  pad.     Per  pad,  50  cts.  net. 

HAYNES'   ANATOMY. 

A  Manual  of  Anatomv.  By  IRVING  S.  Hay'NES,  M.  D.,  Professor  of  Prac- 
tical Anatomy  in  Cornell  University  Medical  College.  680  pages ;  42  dia- 
grams and  134  full-page  half-tone  illustrations  from  original  photographs  of 
the  author's  dissections.     Cloth,  $2.50  net. 


8  MEDICAL   PUBLICATIONS 

HEISLER'S  EMBRYOLOGY.     Second  Edition,  Revised. 

A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Professor  of 
Anatomy,  Medico-Chirurgical  College,  Philadelphia.  Octavo  volume  of  405 
pages,  handsomely  illustrated.     Cloth,  ^2.50  net. 

HIRST'S  OBSTETRICS.    Third  Edition,  Revised  and  Enlarged. 

A  Text-Book  of  Obstetrics.  By  BARTON  Cooke  Hirst,  M.D.,  Professor 
of  Obstetrics,  University  of  Pennsylvania.  Handsome  octavo  volume  of 
873  pages,  704  illustrations,  36  of  them  in  colors.  Cloth,  ^5.00  net ;  Sheep 
or  Half  Morocco,  ^6.00  net. 

HYDE  &  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES.    2d  Edition,  Revised  and  Greatly  Enlarged. 

Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde,  M.  D.,  Pro- 
fessor of  Skin,  Genito-Urinary,  and  Venereal  Diseases,  and  Frank  H. 
Montgomery,  M.  D.,  Associate  Professor  of  Skin,  Genito-Urinary,  and 
Venereal  Diseases  in  Rush  Medical  College,  Chicago,  111.  Octavo,  594 
pages,  profusely  illustrated.     Cloth,  $4.00  net. 

INTERNATIONAL  TEXT=BOOK  OF  SURGERY.  Two  Volumes. 

By  American  and  British  Authors.  Edited  by  J.  Collins  Warren,  M.  D., 
LL.  D.,  F.  R.C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical  School, 
Boston  ;  and  A.  Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  Lecturer  on  Practical 
Surgery  and  Teacher  of  Operative  Surgery,  Middlesex  Hospital  Medical 
School,  London,  Eng.  Vol.  I.  General  Surgery. — Handsome  octavo,  947 
pages,  with  458  beautiful  illustrations  and  9  lithographic  plates.  Vol.  H. 
Special  or  Regiofial  Surgery. — Handsome  octavo,  1072  pages,  with  471 
beautiful  illustrations  and  8  lithographic  plates.  Prices  per '  volume  : 
Cloth,  ^5.00  net;  Sheep  or  Half  Morocco,  ^6.00  net. 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The 
clinician  and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a 
satisfaction  to  the  editors  as  it  is  a  gratification  to  the  conscientious  reader." — Annals  of 
Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has 
very  many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different 
authors  is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor 
of  each  writer  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the 
technique  of  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up 
to  date  in  a  very  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional 
parts  of  the  body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which 
the  reader  may  not  learn  something  new." — Medical  Record,  New  York. 

JACKSON'S  DISEASES  OF  THE  EYE. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polychnic  and  Col- 
lege for  Graduates  in  Medicine.  i2mo,  volume  of  535  pages,  with  178  illus- 
trations, mostly  from  drawings  by  the  author.     Cloth,  ^2.50  net. 

KEATINQ'S  LIFE  INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating,  M.  D.,  Fellow 
of  the  College  of  Physicians  of  Philadelphia  ;  Ex-President  of  the  Association 
of  Life  Insurance  Medical  Directors.  Royal  octavo,  211  pages.  With 
numerous  illustrations.     Cloth,  ^2.00  net. 

KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm.  W. 
Keen,  M.  D.,  LL.D.,  F,  R.  C.  S.  (Hon.),  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia,  etc. 
Octavo  volume  of  386  pages,  illustrated.     Cloth,  $3.00  net. 


OF   W.  B:  SAUNDERS  ^   CO. 


KEEN'S  OPERATION  BLANK.    Second  Edition,  Revised  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.  Required  in  Various 
Operations.  Prepared  by  W.  W.  Kken.  M.  D.,  LL.D.,  F.  R.  C.S.  (Hon.), 
Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson 
Medical  College,  Philadelphia.     Price  per  pad,  of  50  blanks,  50  cts.  net. 

KYLE  ON  THE  NOSE  AND  THROAT.    Second  Edition. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical 
Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  646  pages  ;  over  150  illustrations  and  6  lithographic  plates. 
Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  ^5.00  net. 

LAINE'S  TEMPERATURE  CHART. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.  D.  Size  8  x  135^ 
inches.  A  conveniently  arranged  Chart'  for  recording  Temperature,  with 
columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Re- 
marks, etc.  On  the  back  of  each  chart  is  given  the  Brand  treatment  of 
Typhoid  Fever.     Price,  per  pad  of  25  charts,  50  cts.  net. 

*LEVY,  KLEMPERER,  AND  ESHNER'S  CLINICAL  BACTERI- 
OLOGY. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Levy,  Professor 
in  the  University  of  Strasburg,  and  Dr.  Felix  Klemperer,  Privatdocent 
in  the  University  of  Strasburg.  Translated  and  edited  by  AUGUSTUS  A. 
Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic. 
Octavo,  440  pages,  fully  illustrated.     Cloth,  $2.50  net. 

LOCKWOOD'S    PRACTICE    OF    MEDICINE.    Second  Edition, 
Revised  and  Enlarged. 

A  Manual  of  the  Practice  of  Medicine.     By  GEORGE  RoE  LocKWOOD, 

M.  D.,  Attending  Physician  to  Bellevue  Hospital,  New  York.  Octavo,  847 
pages,  fully  illustrated,  including  22  colored  plates.     Cloth,  $4.00  net. 

LONG'S  SYLLABUS  OF  GYNECOLOGY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Cloth, 
interleaved,  ^i.oo  net. 

MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  V^.  Macdonald,  ^L  D.  Edin., 
F.  R.  C.  S.  Edin.,  Professor  of  Practice  of  Surgery  and  Clinical  Surger}^ 
Hamline  University.  Handsome  octavo,  800  pages,  fully  illustrated.  Cloth, 
$5.00  net ;  Sheep  or  Half  Morocco,  $6.00  net. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 
Second  Edition,  Revised  and  Enlarged. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work  in 
Pathologv,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on  Post- 
Mortem  Technique  and  the  Performance  of  Autopsies.  By  FRANK  B. 
Mallory,  A.m.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard  Uni- 
versity Medical  School,  Boston;  and  James  H.  Wright,  A.M..  M.D., 
Instructor  in  Pathology,  Harvard  University  Medical  School,  Boston. 
Octavo,  432  pages,  fully  illustrated.     Cloth,  ^3.00  net. 


lo  MEDICAL    PUBLICATIONS 

McCLELLAN'S  ANATOMY  IN  ITS  RELATION  TO  ART. 

Anatomy  in  its  Relation  to  Art.  An  Exposition  of  the  Bones  and  Muscles 
of  the  Human  Body,  with  Reference  to  their  Influence  upon  its  Actions 
and  External  Form.  By  GEORGE  McClellan,  M.  D.,  Professor  of  Anat- 
omy, Pennsylvania  Academy  of  Fine  Arts.  Handsome  quarto,  9  by  11^ 
inches.  Illustrated  with  338  original  drawings  and  photographs,  260  pages 
of  text.     Dark  Blue  Vellum,  ^10.00  net ;   Half  Russia,  ;^i2.oo  net. 

McCLELLAN'S  REGIONAL  ANATOMY. 

Regional  Anatomy  in  its  Relations  to  Medicine  and  Surgery.  By  George 
McClellan,  M.  D.,  Professor  of  Anatomy  at  the  Pennsylvania  Academy 
of  Fine  Arts.  In  two  handsome  quarto  volumes,  884  pages  of  text,  and 
97  full-page  chromo-lithographic  plates,  reproducing  the  author's  original 
dissections.     Price:  Cloth,  ^12.00  net ;   Half  Russia,  ^15.00  net. 

McFARLAND'S    PATHOGENIC    BACTERIA.      Third   Edition, 
increased  in  size  by  over  100  Pages. 

Text-Book  upon  the  Pathogenic  Bacteria.  By  JOSEPH  McFarland,^ 
M.  D.,  Professor  of  Pathology  and  Bacteriology,  Medico-Chirurgical  Col- 
lege, Phila.,  etc.     Octavo,  621  pages,  finely  illustrated.     Cloth,  ^3.25  net. 

MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  ARTHUR  V.  MEIGS,  M.  D.  Bound  in  limp 
cloth,  flush  edges,  25  cts.  net. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  jAMES  E.  MooRE,  M.  D.,  Professor 
of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  University  of 
Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume  of  356  pages, 
handsomely  illustrated.     Cloth,  ^2.50  net. 

MORTEN'S  NURSES'  DICTIONARY. 

Nurses'  Dictionary  of  Medical  Terms  and  Nursing  Treatment.  Containing 
Definitions  of  the  Principal  Medical  and  Nursing  Terms  and  Abbreviations  ; 
of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations, 
Foods,  Appliances,  etc.  encountered  in  the  ward  or  in  the  sick-room.  By 
HoNNOR  Morten,  author  of"  How  to  Become  a  Nurse,"  etc.  i6mo,  140 
pages.     Cloth,  ^i.oo  net. 

NANCREDE'S  ANATOMY  AND  DISSECTION.    Fourth  Edition. 

Essentials  of  Anatomy  and  Manual  of  Practical  Dissection.  By  Charles 
B.  Nancrede,  M.  D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
University  of  Michigan,  Ann  Arbor.  Post-octavo,  500  pages,  with  full-page 
lithographic  plates  in  colors  and  nearly  200  illustrations.  Extra  Cloth  (or 
Oilcloth  for  dissection-room),  ^2.00  net. 

NANCREDE'S  PRINCIPLES  OF  SURGERY. 

Lectures  on  the  Principles  of  Surgery.  By  Charles  B.  Nancrede,  M.  D., 
LL.D,,  Professor  of  Surgery  and  of  Clinical  Surgery,  University  of  Michigan, 
Ann  Arbor.     Octavo,  398  pages,  illustrated.     Cloth,  ^2.50  net. 


OF  W.  B.  SAUNDERS  er*  CO.  n 


NORRIS'S    SYLLABUS    OF    OBSTETRICS.      Third     Edition, 
Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department,  University  of 
Pennsylvania.  By  RICHARD  C.  NORRIS,  A.  M.,  M.  D.,  Instructor  in  Obstet- 
rics and  Lecturer  on  Clinical  and  Operative  Obstetrics,  University  of  Penn- 
sylvania.    Crown  octavo,  222  pages.     Cloth,  interleaved,  ^2.00  net. 

OQDEN  ON  THE  URINE. 

Clinical  Examination  of  the  Urine  and  Urinar\'  Diagnosis.  A  Clinical  Guide 
for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Surgery.  By  J. 
Bergen  Ogden,  M.  D.,  lately  Instructor  in  Chemistry,  Harvard  Univer- 
sity Medical  School.  Handsome  octavo,  416  pages,  with  54  illustrations 
and  a  number  of  colored  plates.     Cloth,  $3.00  net. 

PENROSE'S  DISEASES  OF  WOMEN.    Fourth  Edition,  Revised. 

A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose,  M.  D., 
Ph.  D.,  formerly  Professor  of  Gynecology  in  the  Universityof  Pennsylvania. 
Octavo  volume  of  538  pages,  handsomely  illustrated.     Cloth,  $3.75  net. 

PYE'S  BANDAGING. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  concerning 
the  Immediate  Treatment  of  Cases  of  Emergency.  By  Walter  Pve, 
F.  R.  C.  S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo, 
over  80  illustrations.     Cloth,  flexible  covers,  75  cts.  net. 

PYLE'S  PERSONAL  HYGIENE. 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a  Physiologic  Basis. 
Edited  by  Walter  L.  Pyle,  M.  D.,  Assistant  Surgeon  to  the  Wills  Eye 
Hospital,  Philadelphia.  Octavo  volume  of  344  pages,  fully  illustrated. 
Cloth,  $1.50  net, 

RAYMOND'S    PHYSIOLOGY.      Second  Edition,   Entirely    Re= 

written  and  Greatly  Enlarged. 

A  Text-Book  of  Physiology.  By  Joseph  H.  Raymond,  A.M.,  M.  D., 
Professor  of  Physiology  and  Hygiene  in  the  Long  Island  College  Hospital, 
and  Director  of  Physiology  in  Hoagland  Laboratory,  New  York.  Octavo, 
668  pages,  443  illustrations.     Cloth,  $3.50  net. 

SALINGER  AND  KALTEYER'S  MODERN  MEDICINE. 

Modern  Medicine.  By  JULIUS  L.  Salinger,  M.D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College  ;  and  F.  J.  Kalteyer,  M.  D., 
Assistant  in  Clinical  Medicine,  Jefferson  Medical  College.  Handsome 
octavo,  801  pages,  illustrated.     Cloth,  $4.00  net. 

SAUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby,  M.  D, 
Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the  Royal 
Medico-Chirurgical  Society  ;  Professor  of  Medicine  in  Mason  College,  Bir- 
mingham, etc.  Octavo,  434  pages,  with  numerous  illustrations  and  4  colored 
plates.     Cloth,  $2.50  net. 

SAUNDERS'     MEDICAL     HAND=ATLASES.      See    pages     16 
and   17. 


12  MEDICAL  PUBLICATIONS 

SAUNDERS'   POCKET  MEDICAL  FORMULARY.     Sixth  Edi= 

tion,  Revised. 

By  William  M.  Powell,  M.  D.,  author  of  "  Essentials  of  Diseases  of 
Children"  ;  Member  of  Philadelphia  Pathological  Society.  Containing  1844 
formulae  from  the  best-known  authorities.  With  an  Appendix  containing 
Posological  Table,  Formulas  and  Doses  for  Hypodermic  Medication, 
Poisons  and  their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal 
Head,  Obstetrical  Table,  Diet  Lists,  Materials  and  Drugs  used  in  Antiseptic 
Surgery,  Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer, 
Tables  of  Incompatibles,  Eruptive  Fevers,  etc.,  etc.  Flexible  morocco, 
with  side  index,  wallet,  and  flap.     $2.00  net. 

SAUNDERS'  QUESTION=COMPENDS.     See  pages  14  and  15. 
SCUDDER'S  FRACTURES.    Second  Edition,  Revised. 

The  Treatment  of  Fractures.  By  Chas  L.  Scudder,  M.  D.,  Assistant  in 
Clinical  and  Operative  Surgery,  Harvard  University  Medical  School.  Oc- 
tavo, 433  pages,  with  nearly  600  original  illustrations.  Polished  Buckram, 
^^4.50  net;   Half  Morocco,  ^5.50  net. 

SENN'S  QENITO-URINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female.  By  NICH- 
OLAS Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical 
College,  Chicago.  Handsome  octavo  volume  of  320  pages,  illustrated. 
Cloth,  ^3.00  net. 

SENN'S  PRACTICAL  SURGERY. 

Practical  Surgery.  By  NICHOLAS  Senn,  M.  D.,  Ph.  D.,  LL.D.,  Professor 
of  Surgery,  Rush  Medical  College,  Chicago.  Handsome  octavo  volume 
of  1133  pages,  642  illustrations.  Cloth,  ^6.00  net;  Sheep  or  Half  Morocco, 
$7.00  net.     By  Subscription. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged  in  conformity 
with  "An  American  Text-Book  of  Surgery."  By  NICHOLAS  SENN,  M.  D., 
Ph.D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 
Cloth,  ^1.50  net. 

SENN'S  TUMORS.     Second  Edition,  Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  NICHOLAS  SENN,  M.  D., 
Ph.  D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  718  pages,  with  478  illustrations,  includ- 
ing 12  full-page  plates  in  colors.  Cloth,  ^5.00  net  ;  Sheep  or  Half 
Morocco,  ^6.00  net. 

SOLLMANN'S  PHARMACOLOGY. 

A  Text-Book  of  Pharmacology.  By  TORALD  SOLLMANN,  M.  D.,  Assistant 
Professor  of  Pharmacology  and  Materia  Medica,  Western  Reserve  Univer- 
sity, Cleveland,  Ohio.  Royal  octavo  volume  of  894  pages,  fully  illustrated. 
Cloth,  ^3.75  net. 


OI'    W.   B.    SAUNDERS  ^^    CO.  1 3 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  anc'  Children  in  Health  and  in  Disease.  By  Louis  Starr, 
M.D.,  Editor  of  "  An  American  Text-Book  of  the  Diseases  of  Children." 
230  blanks  (pocket-book  size),  perforated  and  neatly  bound  in  flexible 
morocco,     $1.25  net. 

STENGEL'S  PATHOLOGY.  Third  Edition,  Thoroughly  Revised. 

A  Text-Book  of  Pathology.  By  ALFRED  STENGEL.  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania;  Visiting  Physician  to  the 
Pennsylvania  Hospital.  Octavo,  873  pages,  nearly  400  illustrations  many 
of  them  in  colors.     Cloth,  $5.00  net ;  Sheep  or  Half  Morocco,  $6.00  net. 

STENGEL  AND  WHITE  ON  THE  BLOOD. 

The  Blood  in  its  Clinical  and  Pathological  Relations.  By  ALFRED  STEN- 
GEL. M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania  ;  and 
C.  Y.  White,  Jr.,  M.  D.,  Instructor  in  Clinical  IVtedicine,  University  of 
Pennsylvania.     In  Press. 

STEVENS'  MATERIA  MEDICA  AND  THERAPEUTICS.     Third 
Edition,  Entirely  Rewritten  and  Greatly  Enlarged. 

A  Text-Book  of  Modem  Therapeutics.  By  A.  A.  Stevens,  A.  M.,  M.  D., 
Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsylvania. 

STEVENS'  PRACTICE  OF  MEDICINE.    Fifth  Edition,  Revised. 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M.,  M.  D., 
Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsylvania.  Spe- 
cially intended  for  students  preparing  for  graduation  and  hospital  examina- 
tions.    Post-octavo,  519  pages  ;  illustrated.     Flexible  Leather,  $2.00  net. 

STEWART'S  PHYSIOLOGY.    Fourth  Edition,  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For  Students  and  Prac- 
titioners. By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc,  Professor  of  Physiol- 
ogy and  Histolog\^  Western  Reserve  University,  Cleveland,  Ohio.  Octavo, 
894  pages ;  336  illustrations  and  5  colored  plates.     Cloth,  33-75  net. 

STONEY'S  MATERIA  MEDICA  FOR  NURSES. 

Materia  Medica  for  Nurses.  By  EMILY  A.  M.  Stoney,  late  Superintend- 
ent of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Boston, 
Mass.     Handsome  octavo  volume  of  306  pages.     Cloth,  3i-5o  net. 

STONEY'S  NURSING.    Second  Edition,  Revised. 

Practical  Points  in  Nucsing.  For  Nurses  in  Private  Practice.  By  EMILY 
A.  M.  Stoney,  late  Superintendent  of  the  Training-School  for  Nurses, 
Carney  Hospital,  South  Boston,  Mass.  456  pages,  with  73  engravings  and 
8  colored  and  half-tone  plates.     Cloth,  $1.75  net. 

STONEY'S  SURGICAL  TECHNIC  FOR  NURSES. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  EMILY  A.  ^^.  STONEY, 
late  Superintendent  of  the  Training-School  for  Nurses,  Carney  Hospital, 
South  Boston,  Mass.     i2mo  volume,  fully  illustrated.     Cloth,  $1.25  net. 


14  MEDICAL   PUBLICATIONS. 


THOMAS'S  DIET  LISTS.    Second  Edition,  Revised. 

Diet  Lists  and  Sick-Room  Dietary.  By  JEROME  B.  THOMAS,  M.  D.,  In- 
structor in  Materia  Medica,  Long  Island  Hospital ;  Assistant  Bacteriologist 
to  the  Hoagland  Laboratory.     Cloth,  ^1.25  net.     Send  for  sample  sheet. 

THORNTON'S  DOSE=BOOK  AND  PRESCRIPTION=WRITINQ. 
Second  Edition,  Revised  and  Enlarged. 

Dose-Book  and  Manual  of  Prescription-Writing.  By  E.  Q.  THORNTON, 
M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Philadel- 
phia.    Post-octavo,  362  pages,  illustrated.     Flexible  Leather,  ^2.00  net. 

VECKI'S  SEXUAL  IMPOTENCE^    Tliird  Edition,  Revised. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  VICTOR  G.  Vecki, 
M.  D.  From  the  second  German  edition,  revised  and  enlarged.  Demi- 
octavo,  329  pages.     Cloth,  ^2.00  net. 

VIERORDT'S    MEDICAL    DIAGNOSIS.     Fourth   Edition,  Re= 
vised. 

Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medicine, 
University  of  Heidelberg.  Translated,  with  additions,  from  the  fifth  en- 
larged German  edition,  with  the  author's  permission,  by  Francis  H. 
Stuart,  A.  M.,  M.D.  Handsome  octavo  volume,  603  pages;  194  wood- 
cuts, many  of  them  in  colors.  Cloth,  4.00  net;  Sheep  or  Half-Morocco, 
^5.00  net. 

WATSON'S  HANDBOOK  FOR  NURSES. 

A  Handbook  for  Nurses.  By  J,  K.  Watson,  M.  D.  Edin.  American 
Edition,  under  supervision  of  A.  A.  STEVENS,  A.M.,  M.  D.,  Lecturer  on 
Physical  Diagnosis,  University  of  Pennsylvania.  i2mo,  413  pages,  73  illus- 
trations.    Cloth,  ^1.50  net. 

WARREN'S  SURGICAL  PATHOLOGY.    Second  Edition. 

Surgical  Pathology  and  Therapeutics.  By  John  COLLINS  Warren,  M.  D., 
LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical  School. 
Handsome  octavo,  873  pages  ;  136  relief  and  lithographic  illustrations,  33  in 
colors.  With  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis,  and  a 
series  of  articles  on  Regional  Bacteriology.  Cloth^  ^5.00  net ;  Sheep  or 
Half  Morocco,  ^6.00  net, 

WARWICK  AND  TUNSTALL'S  FIRST  AID  TO  THE  INJURED 

AND  SICK. 

First  Aid  to  the  Injured  and  Sick.  By  F.J.  Warwick,  B.A.,  M.  B. 
Cantab.,  M.  R.  C.  S.,  Surgeon-Captain,  Volunteer  Medical  Staff  Corps, 
London  Companies;  and  A.  C.  TUNSTALL,  M.  D.,  F.  R.  C.  S.  Ed,,  Sur- 
geon-Captain commanding  East  London  Volunteer  Brigade  Bearer  Com- 
pany.    i6mo,  232  pages,  and  nearly  200  illustrations.     Cloth,  ^i.oo  net. 

WOLF'S  EXAMINATION  OF  URINE. 

A  Hand-Book  of  Physiologic  Chemistry  and  Urine  Examination.  By 
Charles  G.  L.  Wolf,  M.  D.,  Instructor  in  Physiologic  Chemistry,  Cor- 
nell University  Medical  College.  i2mo  volume  of  204  pages,  47  illustra- 
tions.    Cloth,  ^1.25  net. 


Sau  nders' 
Question  =  Compend    Series. 

Price,  Cloth,  $i.oo  net  per  copy,  except  when  otherwise  noted. 


Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the  Saunders 
Series,  in  our  opinion,  bears  off  the  palm  at  present." — New  York  Medical  Record. 


1.  Essentials    of    Physiology.       By    Sidney    Budgett,    M.  D.     An   entirely   new 

tijork. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.  D.     Seventh  edition,  revised 

with  an  Appendix  and  a  chapter  on  Appendicitis.  '  ' 

3.  Essentials  of  Anatomy.     By  Charles   B.    Nancrede,    M.  D.     Sixth   edition 

thoroughly  revised  and  enlarged.  ' 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorganic.   By  Lawrence 

Wolff,  M.  D.     Fifth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  Easterly  Ashton,  M.  D.        Fifth    edition, 

revised  and  enlarged. 

6.  Essentials  of  Pathology  and  Morbid  Anatomy.    By  f.  j.  Kalteyer,  m.  d. 

In  preparation. 

7.  Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription- Writing. 

By  Henry  Morris,  M.  D.     Fifth  edition,  revised. 

8.  9.     Essentials  of  Practice   of  Medicine.     By  Henry  Morris,  M.  D.     An  Ap- 

pendix on  Urine  Examination.  By  Lawrence  Wolff,  M.  D.  Third  edition, 
enlarged  by  some  300  Essential  Formulae,  selected  from  eminent  authorities,  by 
Wm.  M.  Powell,  M.  D.     (Double  number,  $1.50  net.) 

10.  Essentials   of   Gynecology.     By   Edwin   B.   Cragin,  M.  D.        Fifth    edition, 

revised. 

11.  Essentials  of  Diseases  of  the  Skin.    By  Henry  w.  Stelwagon,  m.  D. 

Fourth  edition,  revised  and  enlarged. 

12.  Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal  Diseases.    By 

Edward  Martin,  M.  D.     Second  edition,  revised  and  enlarged. 

13.  Essentials  of  Legal  Medicine,  Toxicology,  and  Hygiene.    This  volume  is 

at  present  out  of  print. 

14.  Essentials   of  Diseases   of  the   Eye.     By   Edward  Jackson,   M.  D.     Third 

edition,  revised  and  enlarged. 

IB.     Essentials  of  Diseases  of  Children.     By  William  M.  Powell,  M.  D.    Third 

16.  Essentials  of  Examination  of  Urine.     By  Lawrence  Wolff,  M.  D.     Colored 

"  VoGEL  Scale."     (75  cents  net.) 

17.  Essentials  of  Diagnosis.     By  S.  Solis-Cohen,  M.  D.,  and  A.  A.  Eshner,  M.  D. 

Second  edition,  thoroughly  revised. 

18.  Essentials  of  Practice  of  Pharmacy.     By  Lucius  E.  Sayre.     Second  edition, 

revised  and  enlarged. 

19.  Essentials  of  Diseases  of  the  Nose  and  Throat.    By  £.  B.  Gleason,  m.  d 

Third  edition,  revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  M.  v.  Ball,  M.  D.     Fourth  edition,  revised. 

21.  Essentials  of  Nervous  Diseases  and  Insanity.    By  John  C.  Shaw,  M.  D. 

Third  edition,  revised. 

22.  Essentials  of  Medical  Physics.     By  Fred  J.  Brockway,  M.  D.     Second  edi- 

tion, revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart,  M.  D.,  and   Ed- 

ward S.  Lawrance,  M.  D. 

24.  Essentials  of  Diseases  of  the  Ear.     By  E.  B.  Gleason,  M.  D.     Second  edition, 

revised  and  greatly  enlarged. 

26.     Essentials  of  Histology.    By  Louis  Leroy,  M.  D.     With  73  original  illustrations. 


Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  application. 

15 


Saunders'  Medical  Hand=AtIases. 


VOLUMES  NOW  READY. 

ATLAS    AND    EPITOME    OF    INTERNAL    MEDICINE    AND 
CLINICAL   DIAGNOSIS. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshner, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  179 
colored  figures  on  68  plates,  64  text-illustrations,  259  pages  of  text.  Cloth, 
^3.00  net. 

ATLAS  OF  LEGAL  MEDICINE. 

By  Dr.  E.  R.  von  Hoffman,  of  Vienna.  Edited  by  Frederick  Peter- 
son, M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of  Physicians  and 
Surgeons,  New  York.  With  120  colored  figures  on  56  plates  and  193  beau- 
tiful half-tone  illustrations.     Cloth,  ^3.50  net. 

ATLAS  AND  EPITOME  OF  DISEASES  OF  THE  LARYNX. 

By  Dr.  L.  GRt)NWALD,  of  Munich.  Edited  by  CHARLES  P.  Grayson, 
M.  D.,  Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of  the 
University  of  Pennsylvania.  With  107  colored  figures  on  44  plates,  25  text- 
illustrations,  and  103  pages  of  text.     Cloth,  ^2.50  net. 

ATLAS  AND    EPITOME  OF  OPERATIVE   SURGERY.     Second 
Edition,  Thoroughly  Revised  and  Greatly  Enlarged. 

By  Dr.  O.  Zuckerkandl,  of  Vienna.  Edited,  with  additions,  by  J.  CHAL- 
MERS DaCosta,  M.  D.,  Professor  of  Principles  of  Surgery  and  of  Clinical 
Surgery,  Jefferson  Medical  College,  Philadelphia.  With  40  colored  plates, 
278  text-illustrations,  and  410  pages  of  text.     Cloth,  $3.50  net. 

ATLAS  AND  EPITOME  OF  SYPHILIS  AND  THE  VENEREAL 

DISEASES. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by  L. 
Bolton  Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  University 
and  Bellevue  Hospital  Medical  College,  New  York.  With  71  colored  plates, 
16  text-illustrations,  and  122  pages  of  text.     Cloth,  ^3.50  net. 

ATLAS  AND  EPITOME  OF  EXTERNAL  DIS.  OF  THE  EYE. 

By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With 
76  colored  illustrations  on  40  plates  and  228  pages  of  text.     Cloth,  ^3.00  net. 

ATLAS  AND  EPITOME  OF  SKIN  DISEASES. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
WAGON.  M.  D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical  Col- 
lege, Philadelphia.  With  63  colored  plates,  39  half-tone  illustrations,  and 
200  pages  of  text.     Cloth,  ^3.50  net. 

ATLAS  AND  EPITOME  OF  SPECIAL  PATHOLOGICAL  HIS- 
TOLOGY. 

By  DR.  H.  DUrck,  of  Munich.  Edited  by  LUDVIG  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  I.,  including  Circulatory,  Respiratory,  and  Gastro-intestinal  Tract, 
120  colored  figures  on  62  plates,  158  pages  of  text.  Port  11.,  including 
Liver,  Urinary  Organs,  Sexual  Organs,  Nervous  System,  Skin,  Muscles, 
and  Bones.  123  colored  figures  on  60  plates,  192  pages  of  text.  Per 
volume :  Cloth,  ^3.00  net. 

16 


Saunders'  Medical  Hand=Atlases. 


VOLUMES  JUST   ISSUED 

ATLAS  AND  EPITOME  OF  DISEASES  CAUSED  BY  ACCIDENTS. 

By  Dk.  Ed.  Goleuiewski,  of  Berlin.  Edited,  with  additions,  by  Peakce  Bailey, 
M.  D.,  Attending  Physician  to  the  Department  of  Corrections  and  to  the  Almshouse 
and  Incurable  Hospitals,  New  York.  With  40  colored  plates,  143  text-illustrations,  and 
600  pages  of  te.\t.     Cloth,  $4  00  net. 

ATLAS  AND  EPITOME  OF  GYNECOLOGY. 

By  Dr.  O.  Schaeffeh,  of  Heidelberg.  From  the  Second  Revised  German  Edition. 
Edited,  with  additions,  by  Richard  C.  Norris,  A,  M.,  M.  D.,  Gynecologist  to  the 
Methodist  Episcopal  and  the  Philadelphia  Hospitals ;  Surgeon-in-Charge  of  Preston 
Retreat,  Philadelphia.  With  90  colored  plates,  65  text-illustrations,  and  308  pages  of 
text.     Cloth,  $350  net. 

ATLAS  AND  EPITOME  OF  THE  NERVOUS  SYSTEM  AND  ITS  DISEASES. 

By  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Revised  and  Enlarged 
German  Edition.  Edited,  with  additions,  by  Edward  D.  Fisher,  M.  D.,  Professor  of 
Diseases  of  the  Nervous  System,  University  and  Bellevue  Hospital  Medical  College, 
N.  Y.     With  83  plates  ;  copious  text.     $3.50  net. 

ATLAS  AND  EPITOME  OF  LABOR  AND  OPERATIVE  OBSTETRICS. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Fifth  Revised  and  Enlarged  German 
Edition.  Edited,  with  additions,  by  J.  Clifton  Edgar,  M.  D.,  Professor  of  Obstetrics 
and  Clinical  Midwifery,  Cornell  University  Medical  School.  With  126  colored  illustra- 
tions.    32.00  net. 

ATLAS  AND  EPITOME  OF  OBSTETRICAL  DIAGNOSIS  AND  TREATMENT. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  and  Enlarged  Ger- 
man Edition.  Edited,  with  additions,  by  J.  Clifton  Edgar,  M.  D.,  Professor  of 
Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medical  School.  72  colored 
plates,  numerous  te.xt-illustrations,  and  copious  text.     $3.00  net. 

ATLAS  AND   EPITOME   OF    OPHTHALMOSCOPY  AND   OPHTHALMOSCOPIC 
DIAGNOSIS. 

By  Dr.  O.  Haab,  of  Zurich.  From  the  Third  Revised  and  Enlarged  German  Edi- 
tion. Edited,  with  additions,  by  G.  E.  de  Schweinitz,  M.  D.,  Professor  of  Ophthal- 
mology, Jefferson  Medical  College,  Philadelphia.  With  152  colored  figures  and  82 
pages  of  text.     Cloth,  $3.00  net. 

ATLAS  AND  EPITOME  OF  BACTERIOLOGY. 

Including  a  Hand-Book  of  Special  Bacteriologic  Diagnosis.  By  Prof.  Dr.  K.  B. 
Lehmann  and  Dr.  R.  O.  Neumann,  of  Wiirzburg.  Fro7n  the  Second  Revised  Gerinan 
Edition.  Edited,  with  additions,  by  George  H.  Weaver,  M.  D.,  Assistant  Professor 
of  Pathology  and  Bacteriology,  Rush  Medical  College.  In  Two  Parts.  Part  I.,  con- 
sisting of  632  colored  figures  on  69  plates.  Part  II.,  consisting  of  51X  pages  of  text, 
illustrated.     Per  Part  :  Cloth,  $2.50  net. 

ATLAS  AND  EPITOME  OF  OTOLOGY. 

By  Dr.  Gustav  BrIthl,  of  Berlin,  with  the  collaboration  of  Prof.  Dr.  A.  Politzer,  of 
Vienna.  Edited,  with  additions,  by  S.  MacCuen  Smith,  M.  D.,  Clinical  Professor  of 
Otology,  Jefferson  Medical  College,  Phila.  244  colored  figures  on  39  plates,  99  text- 
cuts,  and  292  pages  of  text.     Cloth,  $3.00  net. 

ATLAS  AND  EPITOME  OF  ABDOMINAL  HERNIA. 

By  Privatdocent  Dr.  Georg  Sultan,  of  Gottingen.  Edited,  with  additions,  by  Wil- 
liam B.  Coley,  Clinical  Lecturer  on  Surgery-,  College  of  Physicians  and  Surgeons,  New 
York.  With  43  colored  figures  on  36  plates,  100  text-cuts,  and  about  250  pages  of  text. 
In  Press. 

ATLAS  AND  EPITOME  OF  FRACTURES  AND  LUXATIONS. 

By  Prof.  Dr.  H.  Helferich,  of  Kiel.  Edited,  with  additions,  by  Joseph  C.  Blood- 
good,  Associate  in  Surgery,  Johns  Hopkins  University,  Baltimore.  With  215  colored 
figures  on  72  plates,  144  text-cuts,  42  skiagraphs,  and  over  300  pages  of  text.    In  Press. 

ATLAS  AND  EPITOME  OF  DISEASES  OF  MOUTH,  THROAT,  AND  NOSE. 

By  Dr.  L.  Grunwald.  of  Munich.  From  the  Second  Revised  and  Enlarged  German 
Edition.     With  42  colored  figures,  39  text-cuts,  and  225  pages  of  text. 


ADDITIONAL  VOLUMES  IN  PREPARATION 
17 


NothnagePs  Encyclopedia 

OF 

PRACTICAL    MEDICINE. 

AMERICAN  EDITION. 
Edited  by  ALFRED  STENGEL,  M.D., 

Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania ;  Visiting 
Physician  to  the  Pennsylvania  Hospital. 

IT  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal  Medicine ; 
and  of  all  the  German  works  on  this  subject,  Nothnagel's  "  Specielle  Pathologic  und 
Therapie  "  is  conceded  by  scholars  to  be  without  question  the  best  System  of  Medicine 
in  existence.  So  necessary  is  this  book  in  the  study  of  Internal  Medicine  that  it  comes 
largely  to  this  country  in  the  original  German.  In  view  of  these  facts,  Messrs.  W.  B. 
Saunders  &  Company  have  arranged  with  the  publishers  to  issue  at  once  an  authorized 
American  edition  of  this  great  encyclopedia  of  medicine. 

For  the  present  a  set  of  ten  volumes,  representing  the  most  practical  part  of  this 
excellent  encyclopedia,  and  selected  with  especial  thought  of  the  needs  of  the  practical 
physician,  will  be  published.  These  volumes  will  contain  the  real  essence  of  the  entire 
work,  and  the  purchaser  will  therefore  obtain  at  less  than  half  the  cost  the  cream  of  the  origi- 
nal.    Later  the  special  and  more  strictly  scientific  volumes  will  be  offered  from  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both  English  and 
German,  and  each  volume  will  be  edited  by  a  prominent  specialist  on  the  subject  to 
which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to  date,  and  the  American  edition 
will  be  more  than  a  mere  translation  of  the  German  ;  for,  in  addition  to  the  matter  contained 
in  the  original,  it  will  represent  the  very  latest  views  of  the  leading  American  and 
English  specialists  in  the  various  departments  of  Internal  Medicine.  The  whole  System 
will  be  under  the  editorial  supervision  of  Dr.  Alfred  Stengel,  who  will  select  the  subjectr 
for  the  American  edition,  and  will  choose  the  editors  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended  over  a 
number  of  years,  but  five  or  six  volumes  will  be  issued  dunng  the  coming  year,  and  the 
remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume  will  be  revised  to  the 
date  of  its  publication  by  the  eminent  editor.  This  will  obviate  the  objection  that  has 
heretofore  existed  to  systems  published  in  a  number  of  volumes,  since  the  subscriber  will 
receive  the  completed  work  while  the  earlier  volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been  to  compel 
physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases  to  be  undesirable. 
Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be  given  the  opportunity  of 
subscribing  for  the  entire  System  at  one  time;  but  any  single  volume  or  any  number  of 
volumes  may  be  obtained  by  those  who  do  not  desire  the  complete  series.  This  latter 
method,  while  not  so  profitable  to  the  publishers,  offers  to  the  purchaser  many  advan- 
tages which  will  be  appreciated  by  those  who  do  not  care  to  subscribe  for  the  entire  work 
at  one  time. 

This  American  edition  of  Nothnagel's  Encyclopedia  will,  without  question,  form  the 
greatest  System  of  Medicine  ever  produced,  and  the  publishers  are  confident  that  it 
will  meet  with  general  favor  in  the  medical  profession. 

l8 


NOTHNAGEL^S  ENCYCLOPEDIA. 

AMERICAN  EDITION. 

VOLUMES  JUST  ISSUED  AND  IN  PRESS. 

TYPHOID  AND  TYPHUS  FEVERS.     By  Dr.  H.  Curschmann,  of  Leipsic. 

Editor.  "William  Osier,   M.D.,  F.R.C.P.,   Professor  of  the  Principles  and  Practice 

of  Medicine  in  Johns  Hopkins  University,  Bahimore.  Handsome  octavo,  646  pages, 
72  valuable  text  illustrations,  and  two  lithographic  plates.  Cloth,  J5.00  net;  Half 
Morocco,  36.00  net.    Just  Ready. 

VARIOLA  (including  VACCINATION).  By  Dk.  H.  Immermann.  of  Basle. 
VARICELLA.  By  Dr.  Th.  von  Jurgensen,  of  Tiibingen.  CHOLERA 
ASIATICA  and  CHOLERA  NOSTRAS.  By  Dr.  C.  Liebermeister,  of 
Tubingen.  ERYSIPELAS  and  ERYSIPELOID.  By  Dr.  H.  Lenhartz,  of 
Hamburg.     PERTUSSIS  and  HAY-FEVER.     By  Dr.'G.  Sticker,  of  Giessen. 

Editor,  Sir  J.  "W.  Moore,  B.A.,  M.D.,  F.R.C.P.I.,  Professor  of  the  Practice  of 
Medicine,  Royal  College  of  Surgeons,  Ireland.  Handsome  octavo  of  682  pages,  illus- 
trated.    Cloth,  $5.00  net  ;   Half  Morocco,  g6.oo  net.    Just  Ready. 

DIPHTHERIA.  By  the  editor.  Measles,  Scarlet  Fever,  Rotheln.  By  Dr.  Th.  von 
JIJRGENSEX,  of  Tiibingen. 

Editor.  William  P.  Northrup,  M.D.,  Professor  of  Pediatrics,  University  and  Belle- 
vue  Medical  College,  N.  Y  Handsome  octavo,  700  pages,  illustrated.  Cloth,  J5.00 
net ;   Half  Morocco,  36.00  net.    Jjist  Ready. 

DISEASES  OF  THE  BRONCHL  By  Dr.  F.  A.  Hoffmann,  of  Leipsic.  DIS- 
EASES OF  THE  PLEURA.  By  Dr.  O.  Rosenbach,  of  Berlin.  PNEU- 
MONIA.    By  Dr.  E.  Aufrecht,  of   Magdeburg. 

Editor,  John  H.  Musser,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Penn- 
sylvania. Handsome  octavo,  700  pages,  7  full-page  lithographs  in  colors.  Cloth,  $5.00 
net ;  Half  Morocco,  $6.00  net.    Just  Ready. 

INFLUENZA  AND  DENGUE.  By  Dr.  O.  Leichtenstern,  of  Cologne.  MALA- 
RIAL DISEASES.     By  Dr.  J.  Mannaberg,  of  Vienna. 

Editor,  Ronald  Ross,  F.R.C.S.,  Eng.,  D.P.H.,  F.R.S.,  Major,  Indian  Medical 
Service,  retired;  Walter  Myers  Lecturer,  Liverpool  School  of  Tropical  Medicine. 
Handsome  octavo,  700  pages,  7  full-page  lithographs  in  colors. 

ANEMIA,  LEUKEMIA,   PSEUDOLEUKEMIA,  HEMOGLOBINEMIA.    By 

Dr.  p.  Ehklich,  of  Frankfort-on-the-Main.  Dr.  A.  Lazarus,  of  Charlottenburg,  and 
Dr.  Felix  Pinkus,  of  Berlin.  CHLOROSIS.  By  Dr.  K.  von  Noorden,  of 
Frankfort-on-the-Main. 

Editor,  Alfred  Stengel,  M.D.,  Professor  of  Clinical  Medicine,  University  of  Pennsyl- 
vania.    Handsome  octavo,  750  pages,  5  full-page  lithographs  in  colors. 

TUBERCULOSIS  AND  ACUTE  GENERAL   MILIARY  TUBERCULOSIS. 

By  Dr.  G.  Cornet,  of  Berlin. 

Editor  to  be  announced  later.     Handsome  octavo,  700  pages. 

DISEASES  OF  THE  STOMACH.     By  Dr.  F.  Riegel,  of  Giessen. 

Editor,  Charles  G.  Stockton,  M.D.,  Professor  of  Medicine,  University  of  Buffalo. 
Handsome  octavo,  800  pages,  with  29  text-cuts  and  6  full-page  plates. 

DISEASES  OF  THE  LIVER.  Bv  Drs.  H.  Quincke  and  G.  Hoppe-Seyler,  of 
Kiel.  DISEASES  OF  THE  PANCREAS.  By  Dr.  L.  Oser,  of  Vienna.  DIS- 
EASES OF  THE  SUPRARENALS.  By  Dr.  E.  Neusser,  of  Vienna. 
Editors,  Frederick  A.  Packard,  M.D.,  Physician  to  the  Pennsylvania  and  to  the 
Children's  Hospitals,  Philadelphia  ;  and  Reginald  H.  Fitz,  A.M.,  M.D.,  Hersey 
Professor  of  the  Theory  and  Practice  of  Physic,  Harvard  University. 

DISEASES  OF  THE  INTESTINES  AND  PERITONEUM.  By  Dr.  Hermann 
Nothnagel,  of  Vienna. 

Editor,  Humphry  D.  RoIIeston,  M.D.,  F.R.C.P.,  Physician  to  and  Lecturer  on 
Pathology  at  St.  George's  Hospital,  London.  Handsome  octavo,  800  pages,  finely 
illustrated. 

19 


CLASSIFIED    LIST 

OF    THE 

MEDICAL    PUBLICATIONS 


W.  B.  Saunders  &  Company. 


ANATOMY,  EMBRYOLOGY,  HIS- 

TOLOGY. 

Bohm,  Davidoff,  and  Huber— A  Text- 
Book  of  Histology, 4 

Clarkson— A  Text-Book  of  Histology,   .  s 

Haynes — A  Manual  of  Anatomy,   ...  7 

Heisler— A  Text-Book  of  Embryology,  .  8 

Leroy — Essentials  of  Histology,  .  ...  15 
McClellan — Anatomy    in    Relation    to 

Art ;   Regional  Anatomy, 10 

Nancrede — Essentials  of  Anatomy,  ...  15 
Nancrede — Essentials  of  Anatomy  and 

Manual  of  Practical  Dissection,  ....  10 

BACTERIOLOGY. 
Ball — Essentials  of  Bacteriology,  ....   15 
Frothingham — Laboratory  Guide, ...      6 
Gorham — Laboratory  Bacteriology,   .    .      7 
Lehmann    and     Neumann— Atlas    of 

Bacteriology, 17 

Levy  and  Klemperer's  Clinical  Bacte- 
riology,           ■     9 

Mallory    and     W^right— Pathological 

Technique, 9 

McFarland— Pathogenic  Bacteria,  ...    10 

CHARTS.  DIET-LISTS,  ETC. 

Griffith— Infant's  Weight  Chart,  ....     7 

Keen — Operation  Blank, 9 

Laine — Temperature  Chart, 9 

Meigs — Feeding  in  Early  Infancy,  ...  10 
Starr — Diets  for  Infants  and  Children,  .  13 
Thomas — Diet-Lists, 14 

CHEMISTRY  AND  PHYSICS. 

Brockway — Ess.  of  Medical  Physics,  .  15 
Jelliffe  and  Diekman — Chemistry,    .   .     22 

^Volf — Examination  of  Urine, 14 

"Wolff — Essentials  of  Medical  Chemistry,    15 

CHILDREN. 

An  American  Text-Book  of  Diseases 

of  Children, 1 

Griffith — Care  of  the  Baby, 7 

Griffith— Infant's  Weight  Chart,  ....  7 

Meigs — Feeding  in  Early  Infancy,  ...  10 

Po\vell — Essentials  of  Dis.  of  Children,  15 

Starr — Diets  for  Infants  and  Children,    .  13 

DIAGNOSIS. 

Cohen  and  Eshner — Essentials  of  Diag- 
nosis,     15 

Corwin — Physical  Diagnosis, 5 

Vierordt — Medical  Diagnosis,    .....    14 


DICTIONARIES. 

The  American  Illustrated  Medical 
Dictionary, 

The  American  Pocket  Medical  Dic- 
tionary,     

Morton — Nurses'  Dictionary, 


EYE,  EAR.  NOSE.  AND  THROAT. 

An  American  Text-Book  of  Diseases 

of  the  Eye,  Ear,  Nose,  and  Throat,  .    .  i 
Briihl  and  Politzer — Atlas  of  Otology,  17 
De  Schweinitz — Diseases  of  the  Eye,  .  6 
Friedrich  and  Curtis — Rhinology,  Lar- 
yngology, and  Otology, 6 

Gleason — Essentials  of  the   Ear,  ....  15 

Gleason — Essentials  of  Nose  and  Throat,  15 

Gradle — Ear,  Nose,  and  Throat,  ....  7 
Grunwald — Atlas  of  Mouth,  Throat,  and 

Nose, 17 

Grunwald  and  Grayson — Atlas  of  Dis- 
eases of  the  Larynx, 16 

Haab  and  de  Schweinitz — Atlas  of  Ex- 
ternal Diseases  of  the  Eye, 16 

Jackson — Manual  of  Diseases  of  the  Eye,  8 

Jackson — ^Essentials  Diseases  of  Eye,    .  15 

Kyle — Diseases  of  the  Nose  and  Throat,  9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 3 

Hyde  and  Montgomery — Syphilis  and 

the  Venereal  Diseases, 8 

Martin — Essentials   of    Minor   Surgery, 

Bandaging,  and  Venereal  Diseases,  .    .  15 

Mracek  and  Bangs— Atlas  of  Syphilis 

and  the  Venereal  Diseases, 16 

Saundby — Renal  and  Urinary  Diseases,  11 

Senn— Genito-Urinary  Tuberculosis,   .   .  la 

Vecki — Sexual  Impotence, 14 

GYNECOLOGY. 

American  Text-Book  of  Gynecology,   .  a 

Cragin — Essentials  of  Gynecology,  ...  15 

Garrigues — Diseases  of  Women,  .    ...  7 

Long — Syllabus  of  Gynecology,    ....  9 

Penrose — Diseases  of  Women, it 

SchaefFer  and  Norris — Atlas  of  Gyne- 
cology,       17 

HYGIENE. 
Abbott — Hygiene  of  Transmissible  Dis- 
eases,   3 

Bergey — Principles  of  Hygiene,  ....  4 

Pyle — Personal  Hygiene, 11 

MATERIA     MEDICA.      PHARMA- 
COLOGY, and  THERAPEUTICS. 
An  American   Text-Book  of  Applied 

Therapeutics, i 

Butler — Text-Book   of  Materia  Medica, 

Therapeutics,  and   Pharmacology,    .    .  5 

Morris — Ess. of  M.  M.  and  Therapeutics,  15 

Saunders'  Pocket  Medical  Formulary,  .  12 

Sayre — Essentials  of  Pharmacy,  ....  15 
Sollmann — Text-Book  of  Pharmacology,  12 

Stevens — Modern  Therapeutics,  ....  13 

Stoney — Materia  Medica  for  Nurses,  .    .  13 

Thornton — Prescription-Writing,     ...  14 


20 


MEDICAL   PUB  Lie  A  TIONS 


21 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Chapman — Medical    Jurisprudence    and 
Toxicology, 5 

Crothers — Morphinism,      5 

Golebiewski  and  Bailey —Atlas  of  Dis- 
eases Caused  by  Accidents, 17 

Hofmannand  Peterson— Atlas  of  Legal 
Medicine,        16 

NERVOUS  AND  MENTAL  DIS- 
EASES, ETC. 

Brower — Manual  of  Insanity 4 

Chapin — Compendium  of  Insanity,  ...     5 
Church    and    Peterson — Nervous  and     5 

Mental  Diseases 5 

Jakob  and   Fisher — Atlas   of    Nervous 

System, 17 

Shaw — Essentials  of  Nervous  Diseases 

and  Insanity, 15 


NURSING. 
Davis — Obstetric  and  Gynecologic  Nurs- 
ing,      6 

Griffith— The  Care  of  the  Baby,  ....  7 

Meigs — Feeding  in  Early  Infancy,    .    .    .  u 

Morten — Nurses'  Dictionary', 10 

Stoney — Materia  Medica  for  Nurses,  .    .  13 

Stoney — Practical  Points  in  Nursing,  .    .  13 

Stoney — Surgical  Technic  for  Nurses,    .  13 

Watson — Handbook  for  Nurses,  ....  14 


OBSTETRICS. 

An  American  Text-Book  of  Obstetrics, 
Ashton — Essentials  of  Obstetrics,  . 
Boisliniere — Obstetric  Accidents, 
Dorland — Modern  Obstetrics,  .  . 
Hirst — Text-Book  of  Obstetrics,  . 
Norris — Syllabus  of  Obstetrics,  .  . 
Schaeffer  and  Edgar — Atlas  of  Obstet 
rical  Diagnosis  and  Treatment,  .    .    . 


17 


PATHOLOGY. 

An  American  Text-Book  of  Pathology-,  2 

Durck — Atlas  of  Pathologic  Histology,  16 

Kalteyer — Essentials  of  Pathology',    .    .  22 
Mallory    and    Wright — Pathological 

Technique, 9 

Senn — Pathology,  and    Surgical    Treat- 
ment of  Tumors, 12 

Stengel — Text-Book  of  Pathology,  ...  13 

'Warren — Surgical  Pathology,    ....  14 

PHYSIOLOGY. 

American  Text-Book  of  Physiology.  .  2 

Raymond — Text-Book  of  Physiology,  .  11 

Stewart — Manual  of  Physiology',  ...  13 

PRACTICE  OF  MEDICINE. 

An  American  Year-Book  of  Medicine 

and  Surgery, 3 

Anders — Practice  of  Medicine, 4 

Eichhorst — Practice  of  Medicine,  ...  6 

Lockwood — Practice  of  Medicine,  ...  9 

Morris — Ess.  of  Practice  of  Medicine,  .  15 

Nothnagel's  Encyclopedia,     .    .    .    .  18,  19 

Salinger  &  Kalteyer — Mod.  Medicine,  ti 

Stevens— Practice  of  Medicine,    ...  13 


SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 2 

Hyde  and  Montgomery — Syphilis  and 

the  Venereal  Diseases, 8 

Martin — Essentials   of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,  .    .  15 

Mracek  and  Stelwagon — Atlas  of  Dis- 
eases of  the  Skin, 16 

SteI\A/agon — Diseases  of  the  Skin,  ...  22 

Stelwagon — Ess.  of  Diseases  of  Skin,  .  15 

SURGERY. 

An  American  Text-Book  of  Surgery,  .  2 
An  American  Year-Book  of  Medicine 

and  Surgery, 3 

Beck — Fractures, 4 

Beck — Manual  of  Surgical  Asepsis      .    .  4 

Da  Costa — Manual  of  Surgery,    ....  6 

Helferich — Atlas  of  Fractures 17 

International  Text-Book  of  Surgery,  8 

Keen — Operation   Blank, 9 

Keen — The  Surgical  Complications  and 

Sequels  of  Typhoid  Fever 8 

Macdonald  —  Siu-gical    Diagnosis    and 

Treatment, 9 

Martin — Essentials  of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,  .    .  15 

Martin — Essentials  of  Surgerj', 15 

Moore — Orthopedic  Surgerj-, 10 

Nancrede — Principles  of  Surgery',  ...  10 

Pye — Bandaging  and  Surgical  Dressing,  11 

Scudder — Treatment  of  Fractures,  ...  12 

Senn — Genito-Urinary  Tuberculosis,  .    .  12 

Senn — Practical  Siu-gery-, 12 

Senn — Syllabus  of  Surgery', 12 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors,  12 

Sultan — Atlas  of  Abdominal  Hernia,  .    .  17 
Warren — Surgical  Pathology  and  Ther- 
apeutics,    14 

Zuckerkandl  and  Da  Costa— Atlas  of 

Operative  Surgery, 16 

URINE  AND  URINARY  DISEASES. 

Ogden — Clinical     Examination     of    the 

Urine, " 

Saundby — Renal  and  Urinary  Diseases,  11 

Wolf — Handbook  of  Urine  Examination,  14 

Wolff — Examination  of  Urine, 15 

MISCELLANEOUS. 

Abbott — Hygiene  of  Transmissible  Dis- 
eases,     3 

Bastin — Laboratory  Exercises  in  Bot- 
any,    4 

Golebiewski  and  Bailey— Atlas  of  Dis- 
eases Caused  by  Accidents,  .       .        •    •  17 
Gould  and   Pyle — Anomalies  and  Curi- 
osities of  INIedicine, 7 

Grafstrom — Massage, 7 

Keating— Examination  for  Life  Insur- 
ance,       ° 

Pyle— A  Manual  of  Personal  Hygiene,  .  11 
Saunders' Medical  Hand-Atlases,  .     16,17 

Saunders'  Pocket  Medical  Formulary,  .  12 
Saunders'  Question-Compends,  .  .  14,  15 
Stewart  and  Lawrence— Essentials  of 

Medical   Electricity, 15 

Galbraith— The  Four  Epochs  of  Wo- 
man's Li^e, 7 


BOOKS  IN  PREPARATION. 


JELLIFFE  AND  DIEKMAN'S  CHEMISTRY. 

A  Text-Book  of  Chemistry.  By  Smith  Ely  Jelliffe,  M.  D.,  Ph.  D., 
Professor  of  Pharmacology,  College  of  Pharmacy,  New  York ;  and 
George  C.  Diekman,  Ph.G.,  M.D.,  Professor  of  Theoretical  and  Ap- 
plied Pharmacy,  College  of  Pharmacy,  New  York,  Octavo,  550  pages, 
illustrated.     Ready  Shortly. 

STELW AGON'S  DISEASES  OF  THE  SKIN. 

Diseases  of  the  Skin.  By  Henry  W.  Stelwagon,  M.  D.,  Clinical  Pro- 
fessor of  Dermatology,  Jefferson  Medical  College,  Philadelphia.  Royal 
octavo,  800  pages,  fully  illustrated.      Ready  Shortly. 

KALTEYER'S  PATHOLOGY. 

Essentials  of  Pathology.  By  F.  J.  Kalteyer,  M.  D.,  Assistant  in 
Clinical  Medicine,  Jefferson  Medical  College  ;  Pathologist  to  the  Lying- 
in  Charity  Hospital,  etc.  In  Saunders'  Question- Compend  Series.  Ready 
Shortly. 

AN   AMERICAN   TEXT=BOOK    OF    LEGAL    MEDICINE    AND 
TOXICOLOGY. 

Edited  by  Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Depart- 
ment, College  of  Physicians  and  Surgeons,  New  York  ;  and  Walter  S. 
Haines,  M.  D.,  Professor  of  Chemistry,  Pharmacy,  and  Toxicology, 
Rush  Medical  College,  Chicago.      In  Press. 

STENGEL  AND  WHITE  ON  THE  BLOOD. 

The  Blood  in  its  Clinical  and  Pathological  Relations.  By  Alfred  Sten- 
gel, M,  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania  ; 
and  C.  Y.  White,  Jr.,  M.  D.,  Instructor  in  Clinical  Medicine,  University 
of  Pennsylvania.     In  Press. 

SULTAN'S  ATLAS  OF  ABDOMINAL  HERNIA. 

Atlas  and  Epitome  of  Abdominal  Hernia.  By  PrivaTDOCENT  Dr. 
Georg  Sultan,  of  Gottingen.  Edited,  with  additions,  by  William 
B.  Coley,  Clinical  Lecturer  on  Surgery,  College  of  Physicians  and  Sur- 
geons, New  York.  With  43  colored  figures  on  36  plates,  100  text-cuts, 
and  about  250  pages  of  text.     In  Saunders''  Hand-Atlas  Series. 

HELFERICH'S  ATLAS  OF  FRACTURES. 

Atlas  and  Epitome  of  Fractures  and  Luxations.  By  Prof.  Dr.  H. 
Helferich,  of  Kiel.  Edited,  with  additions,  by  Joseph  C.  Blood- 
good,  Associate  in  Surgery,  Johns  Hopkins  University,  Baltimore, 
With  215  colored  figures  on  72  plates,  144  text-cuts,  42  skiagraphs, 
and  over  300  pages  of  text.     In  Saunders'  Hand-Atlas  Series. 

22 


COLUMBIA  UNIVERSITY  LIBRARIES 


1010231218 


VOLUMES  NOW  READY. 

Atlas  and  Epitome  of  internal  Medicine  and  Clinical  Diagnodls.    By  Dr.  Chr. 

Jakob  of  Erlangen.  Edited  by  Augustus  A.  Eshnkr,  M.I).,  Professor  of  Clinical 
Medicine  in  the  Philadelphia  Polyclinic.  With  179  colored  figures  on  6S  plates  and 
259  pages  of  text.    Cloth,  $3.00  net. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of  Vienna.  Edited  by  Fred- 
erick Peterson,  M.D.,  Chief  of  Clinic,  Nervous  Department,  College  of  Physicians 
and  Surgeons,  New  York.  With  120  colored  figures  on  56  plates  and  19-^  half-tone 
illustration^     '^'-" 

Atlas  aiT 

Edited 
Depar 
on  44 

Atlas  a 

Edite 
Clinic 
217  ill 

Atlas  ^ 

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Urina 
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Atlas  a 

Edite 
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Atlas  i 

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and  2' 

Atlas  a 

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Atlas  i 

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Atlas  i 

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Atlas, 

Jakob,  of  Erlangen.     I'rom  the  Second.  Kevisea  K^erman  iLaintm.     x:^.vv.<^  -_,  ^«., 

D.  Fisher,  M.  D.,  Professor  of  Diseases  of  the  Nervous  System,  University  and  Bellevue 
Hospital  Medical  College,  New  York.  With  83  plates  and  215  pages  of  text.  Cloth, 
$3.50  net. 

Atlas  and   Epitome  of    Ophthalmoscopy  and  Ophthalmoscopic  Diagnosis.    By 

Dr  O  Haab,  of  Zurich.  From  the  Third  Enlarged  German  Edition  Edited  by  Cr. 
E  DE  ScHWEiNiTZ,  M.D.,  Profcssor  of  Ophthalmology',  Jefferson  Medical  College, 
Philadelphia.     152  colored  figures  and  82  pages  of  text.     Cloth,  $3.00  net. 

Atlas  of  Bacteriology  and   Text=Book  of  Special  Bacteriologic  Diagnosis.    By 

Prof.  Dr.  K.  B.  Lehmann  and  Dr.  R.  O.  Neumann,  of  W  urzburg.  Frovi  the  Second 
Revised  German  Edition.  Edited  by  George  H.  Weaver,  M.  D.,  Assistant  Professor 
of  Pathology  and  Bacteriology,  Rush  Medical  College,  Chicago.  Two  volumes,  with 
over  600  colored  lithographic  figures,  and  500  pages  of  text. 

ADDITIONAL  VOLUMES  IN  PREPARATION. 

T5     tf'_l 


